Pregnant People - Key Activity 17

KEY ACTIVITY #17:

Continue to Develop Referral Relationships and Pathways


 

This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; pre-visit planning and care gap reduction; care coordination; behavioral health integration; address social needs.

 

Overview

Delivery of quality perinatal care encompasses not only clinic and hospital-based obstetric services, preventative care services, and coordination of medical and behavioral healthcare but also referrals for specialty care, social supports, dental care, and other needs of patients, such as birth classes or parenting programs. As a result, coordination of care is more complex and often involves referrals outside the practice structure. Examples include referrals from the practice to a provider (e.g., maternal fetal medicine specialty providers) as well as referrals to behavioral health and social services providers (e.g., WIC, CalFRESH, and CalEarn). A referral network also includes acute and subacute facilities, such as hospitals, emergency departments and residential treatment facilities where a patient may receive treatment and the outcome of treatment is necessary for the ongoing care of the patient in the practice.

This activity addresses common steps that your practice can take to optimize both the referral pathways and outcomes. Prioritize the practice of “ closed loop referrals” in which there is a feedback mechanism to ensure that a referral made by one provider to another is completed and followed up appropriately; “closed loop referrals” leads to greater patient and provider satisfaction. This activity builds on an inventory of existing referral services outside the clinic and identifies steps that can be taken to support the systematic management of the referral process.

When a patient requires a referral to obtain needed services outside the clinic, the process is a point of vulnerability and a significant percent of specialty referrals aren’t completed, in part due to missing information, misguided referrals and faulty communications.[1] [2] In the context of perinatal care, if a referral is not completed, patients may not receive needed services, which can lead to decreased quality of care, decreased patient and provider satisfaction and, ultimately, poorer health outcomes for pregnant people and their babies.[3] The National Committee for Quality Assurance (NCQA) recognizes the importance of referral networks and their management as a core component of patient-centered medical home activities.[4] Building a reliable network of service partners and processes to provide information necessary to inform referrals as well as having mechanisms to track referral results is an important part of providing coordinated care that is person-centered.

A contributor to inequity in perinatal health outcomes is unequal access to services and resources to help patients with their condition.[5] The heart of this activity is to empower both the care team and patients through development and maintenance of a robust process to help patients access medical, behavioral health and community resources.

Many factors can impact whether or not a patient accesses a referral, including language, culture and lack of understanding of why referral is being requested. Lack of understanding of why a referral is being sought is often a barrier for patients to follow up with a referral, particularly if a patient is not experiencing symptoms. When appropriate, referrals for social needs and to community health programs can help address barriers, including those around transportation, language and basic needs of food and housing stability, all of which are associated with poorer health outcomes.

Action steps and roles

1. Identify types of referral partners that your practice needs and gaps in resource availability.

  • Some examples to consider for perinatal care include maternal fetal medicine specialists; sites for ultrasound and other relevant imaging; cardiology; social services providers; substance use providers; and social service providers, including community-based organizations with resources to support patients experiencing homelessness, foster youth, adolescent pregnant patients, and pregnant patients with high frequencies of emergency department visits.
  • Encourage close communication with Medi-Cal managed care plans, enhanced care providers or lead care managers, and community support providers.
  • In areas where you have gaps in referral providers, telehealth services may be an option. For further information on telehealth services, including e-consult, synchronous, asynchronous, and e-visits, contact your managed care plan and/or refer to Telehealth Reimbursement Guide (Pages 14 to 16). Referral processes and tracking are also important to establish for telehealth as well as in-person services.
  • Note that there is a shortage of behavioral health clinicians in many parts of California. As you continue to expand your network of off-site behavioral health providers to meet pressing behavioral health needs, also consider behavioral health integration strategies including expanding your practice’s capacity for providing integrated behavioral health services. See the PHMI People with Behavioral Health Conditions Guide for more about deepening and expanding integrated care.
  • Work with the care teams for pregnant people to identify gaps in referral resources that could enhance implementation of evidence-based care.
  • Use social health screening results that have been disaggregated by REAL and SOGI alongside patient and family feedback to identify unmet needs for which resource relationships have not been established.

2. Assess what tools would be beneficial for the core elements of your referral process.

Examples include (see resources below):

  • Referral request form | Determine what information is required for the provider who is receiving the referral. Information may include the requested service, timing (urgent vs. standard), minimum necessary information, such as patient contact information and applicable demographics, and appropriate clinical and social support questions. For pregnancy-specific referrals, some specialists require additional information, such as working due date, pertinent labs and previous ultrasounds.
  • Referral tracking spreadsheet or software | Information in a tracking system can include date of referral, appointment status and whether follow up is needed. Reach out to your Medi-Cal managed care plans as you are developing referral tracking processes. The MCPs are required to show that Medi-Cal patients are being connected to the services that they are eligible for and referred to; this includes preventive services, specialty services and social services. The MCP may be a good resource for tools such as those needed for tracking and reporting.
  • Referral workflow diagram | A visual representation or workflow diagram can support staff in the referral process. The Institute for Healthcare Improvement (IHI)’s Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era provides a visual nine-step closed loop referral process for specialty referrals, as well as suggestions for improving the process.

3. Assess what tools would be beneficial in enhancing and tracking your referral process.

  • Referral guidelines | For social services, positive responses to screening questions and tools may be the prompt for referral. Other types of referrals may be optimized by having documented referral guidelines, such as information needed by specialty provider in order to best answer referral questions.
  • Communication templates | For high-volume or frequent referral types, a standardized template for communication between the clinic and referral staff can help ensure that that essential information is conveyed efficiently. Examples may include referral letters, progress notes and post-visit summaries of plan of care.
  • Patient education materials (develop in conjunction with referral network) | Educational materials and resources for patients that explain the referral process and what to expect can enhance patient understanding and support referral completion. In addition, consider training medical assistants as well as any dedicated care coordination staff in evidence-based communication techniques, such as teach-back or motivational interviewing to leverage team-based care in supporting the patient to follow through with the referral after the visit.
  • Staffing | Given the specifics of perinatal referrals, consider assigning dedicated staff to pregnancy-related referrals. This allows the staff member to cultivate relationships with specialists and ensure referrals are processed efficiently, given the time sensitivity of many perinatal referrals.

4. Develop approaches to fill resource gaps.

Suggested team member(s) responsible: Clinic leadership.

  • Outreach to your managed care plan (MCP) to understand what resources are available. MCPs are required to have online provider directories, which include specialists, which can be a resource used by a clinic to help find contracted specialists near the patient's home. In addition to comprehensive networks of over a dozen core specialty providers and information on behavioral health and substance use resources, many MCPs are building links to access community based resources in addition to the 14 Medi-Cal Community Supports and extended care management teams through referral platforms that act as a hub to coordinate social needs for patients.
  • Identify external providers and community resources that can serve as partners in care, and use the established referral process to fill gaps in care they can address.
  • Meet and schedule time with high-volume providers, including community-based organizations, to develop a mutual understanding of goals of referrals and opportunities for development of shared processes (e.g., referral form).
  • The American Academy of Pediatrics (AAP) offers a sample tool to develop a resource list.

5. Regularly review and update the referral processes and network.

Suggested team member(s) responsible: Clinic leadership.

  • As new patient needs are identified, use that opportunity to identify potential resources and expand the referral network. If practices have trouble accessing a contracted specialist for their patient because of either overly long wait times or that they are no longer accepting new patients, the MCP is required to approve an out-of-network referral to a more available specialist.
  • On a periodic basis, review referral tracking reports to identify referral resources that are used most frequently and use that information to reinforce the relationships and provide feedback on value.
  • Review referral tracking reports to identify resources for which loop closure is lacking or from whom required information is not being received on a regular basis. Outreach to these organizations to reinforce expectations or, if necessary, identify a replacement resource for the network.
  • For going deeper in tracking quality improvement metrics, practices can develop metrics to assess the effectiveness of the referral network. This might include tracking referral completion rates, patient satisfaction, and time from referral to specialist appointment.

Endnotes

  1. Weiner M, Perkins AJ, Callahan CM. Errors in completion of referrals among older urban adults in ambulatory care. J Eval Clin Pract. 2010;16(1):76-81. doi:10.1111/j.1365-2753.2008.01117.x 
  2. Mehrotra A, Forrest CB, Lin CY. Dropping the baton: specialty referrals in the United States. Milbank Q. 2011;89(1):39–68. doi: 10.1111/j.1468-0009.2011.00619.x. 
  3. Mehrotra A, Forrest CB, Lin CY. Dropping the baton: specialty referrals in the United States. Milbank Q. 2011;89(1):39–68. doi: 10.1111/j.1468-0009.2011.00619.x. 
  4. https://www.ncqa.org/programs/health-care-providers-practices/patient-centered-medical-home-pcmh/ 
  5. Cai C, Gaffney A, McGregor A, Woolhandler S, Himmelstein DU, McCormick D, et al. Racial and ethnic disparities in outpatient visit rates across 29 specialties. JAMA Internal Medicine. 2021 Nov 1;181(11):1525. doi:10.1001/jamainternmed.2021.3771