Navigating the Inherient Dangers of Patient Referrals

  Like any relationship, the bond between a healthcare provider and a patient is heavily based on faith, trust, and communication. Patients rely on their providers to be their advocates, to always have their best interests at the forefront, and to provide them with all the information needed regarding their care. Clinicians know this goes without saying. But do all wound care patients realize they equally need to communicate with their providers across the care continuum to give themselves the best chance at optimal outcomes, especially when they’re referred to another clinician for allied health services or consultation? Not likely. Often, providers must rely on their peers to effectively communicate information regarding their patients’ health. Unfortunately, this is not always a favorable outcome, according to a recent anonymous survey conducted by readers and the editorial board of Today’s Wound Clinic that reveals 46.5 percent of clinicians experience difficulty maintaining regular communication with their peers after a referral is made. (See Survey Stat No. 1. Additional survey results are presented throughout this article and are available at www.todayswoundclinic.com.) As troubling as this may be, there’s little more that can be done beyond making an individualized effort to promote the “team” approach to care. For clinicians who’ve been in the profession for several years and/or have practiced in one community for a stretch of time, leadership may be needed to encourage patients and fellow providers to foster open lines of communication.

Referrals: Here to Stay

  The wound care community has long espoused the importance of taking a team approach to treatment, and providing timely referrals is a critical aspect within the care continuum. Clinicians place a wealth of trust in fellow providers when seeking consultation. This establishment of trust is fundamental not only to patients’ well-being but to the trust that they, in turn, have for providers. Additionally, wound care clinicians need to make time to follow up with referred peers in order to build a comprehensive assessment of the patient throughout the care process. A new practitioner or one who is new to a community may struggle with a degree of trial and error when it comes to finding those specialists who provide top-quality care and communicate findings. In this article, two members of TWC’s editorial board offer a sampling of their experiences as they relate to the referral process and suggest how to establish as well as maintain trust among fellow providers and patients when a referral is necessary.

The ‘I’ In ‘Team’

Desmond Bell, DPM, CWS   I learned early in my career that wound care success is often dependent upon an appreciation and understanding of the variety of metabolic processes that my patients live with as complicating factors responsible for the development and persistence of their nonhealing wounds. Therefore, I quickly familiarized myself with the endocrinologists, cardiologists, neurologists, nephrologists, and vascular surgeons, for starters, when I began to practice in my region (Jacksonville, FL). I also began to realize that most of my patients were also under the care of primary physicians, nurse practitioners, and physician assistants. So, I’ve always made it a priority to remind all the providers with whom I’m making referrals or whom my patients are likely to come into contact with that hypertension, neuropathy, coronary artery disease, peripheral arterial disease, hypothyroidism, and renal disease, for starters, are common among my patient population.   Looking back, it probably took me about six years to find the vascular specialist I’m most comfortable working with. Although we do not work in the same practice, the lines of communication between our practices and each other are a stark contrast to what had been my prior referral pattern experience, which I’d describe as a “black hole” that was impersonal and never reassuring despite the solid reputations of the surgeons I came to know. There were instances when referrals would have the net effect of casting my patients into outer space. This aspect of not knowing surgeons personally was the result of factors I could appreciate, namely the time demands placed on them and the daily aspects of managing and working in a busy medical practice that I faced. More often than not, courtesy letters became a substitute for direct conversation.

Point of No Return

  On more than one occasion, patients whom I had referred to a vascular specialist for consultation regarding an underlying concern of vascular insufficiency were not returning for their wound care. In several extreme instances, patients eventually arrived after undergoing a leg amputation, with no communication from the “consulting” surgeon. The flood of emotions associated with this type of perceived disrespect on my part only amplified the fact that my patients had trusted my role as a wound healer, but my efforts were undermined without as much as a phone call. I have heard stories from colleagues who’ve encountered similar situations that indicate there are specialists who are practicing within their own “silos” and are not embracing a team approach to wound care and limb preservation. I’m often baffled that such a pattern could persist despite the recognition of wound centers as providing a delivery system of care that surpasses what is typical of a physician’s office.

Earning Trust

  Regardless, I’ve learned to attempt to gain the trust of patients during my first encounter with them by establishing dialogue that is of the two-way variety. When patients are engaged in their wound care, the odds of a successful outcome increase instinctively. I inform all patients that they’re critical to the wound care team and share a responsibility with other team members. This includes the need to communicate with me, whether that is regarding changes in their symptoms or an update following any visits they’ve had with another provider. As for developing interdisciplinary communication with providers, the importance of timely correspondence cannot be emphasized enough. Whether due to fear of losing patients, “turf wars” within the community, or simply poor communications skills, a failure to communicate between providers only breeds animosity. Ensuring this communication is easier said than done, but is nevertheless necessary. An easy phone call can allow you to emphasize your role as the coordinator of care between providers in an attempt to keep patients from becoming “lost.” Meanwhile, a mutual respect that’s built for each other’s work can quickly lead to increased referrals that benefit numerous patients and offer you mutual introductions to a number of other providers in a variety of specialties both locally and nationally.   By taking it upon myself to open lines of communication between my patients and my peers, I’ve come to the realization that referrals do not have to be wrought with fear of the unknown or the danger of losing a patient. I’ve taken control and know that I have improved quality of care and have gained the recognition of my role as the conduit of such care among my patients and peers.

Collaborating to Face Challenges

Moira Hayes, MHA, RRT, CHT   I opened a wound care and hyperbarics department in a small city 60 miles south of Houston, TX, in early 1997. The hospital was small, but we were fortunate to have a medical staff that was very diverse and could provide almost all the care our patients needed within one facility. We did not, however, have a vascular program, nor did we have interventional cardiologists. For two years, I searched the city of Houston, home of the country’s largest medical center and two medical schools, for a physician willing to perform vascular procedures on our patients. None of the physicians with whom I met were willing to care for our patient population. With the majority of our patients living with diabetic vasculopathy, placing stents and performing other vascular procedures “was not appealing” to these physicians. Instead, the surgeons I met with were interested in having a patent stent and good blood flow one year from the procedure and maintaining positive outcome statistics. Those results were not likely to happen with our patients. The outcome I was interested in remained getting the wounds healed while potentially allowing patients to avoid leg amputation. Our patients might not have had blood flow one year later, but they may still be walking.

Persistence Pays Off

  By continuing to research and network, I ultimately met a vascular surgeon who practiced in Houston who was willing to accept our patients. It was a bit of a commute, but I believed it to be a valuable opportunity for patients. Within three months, he had cared for 18 patients. It was the beginning of a wonderful working relationship, or so I thought. Unfortunately, he would go on to decide that many patients could have other services performed at his office, namely wound care. Without provocation, patients we had been sending to him for vascular procedures were not returning to us for continuing wound management. After several discussions I had with the surgeon, we remedied the situation. The physician was willing to continue to see our patients while allowing us to follow up for wound care (after being reminded that it was much more lucrative for him to do vascular surgery on our patients and send them back to the clinic for wound care follow-up, as opposed to losing all of our referrals altogether). Today, our patients receive the care they need from the vascular surgeon as well as our staff in the clinic.   I’m not naive to believe that our clinic’s experience was unique. With physician reimbursement decreasing, all physicians are looking for ways to expand their earning potential. Some communities don’t have access to all the specialties needed to care for complex patients like we all see in wound care. Medical staff politics can make referring patients outside the clinic treacherous.   By refusing to let communication challenges get the better of me and my patients, I’m assuring those patients who are referred for specialized care outside of my clinic are cared for appropriately and comprehensively. I see the results and I make it a priority to follow up with each of them and their surgeon. Desmond Bell is co-founder and executive director of Save A Leg, Save A Life Foundation. Moira Hayes is vice president of operations with HyperbaRXs LLC, Atlanta, GA.