Referral processes and wait times in primary care

Ieva Neimanis; Kathryn Gaebel; Robert Dickson; Richard Levy; Cindy Goebel; Angelo Zizzo; Anne Woods; John Corsini

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RE: Lack of Response for Referrals Appalling
Darren C Cargill

Published on: 01 September 2020
RE: Referral processes and wait times in primary care
Don Eby

Published on: 07 September 2017

Published on: (1 September 2020)
Page navigation anchor for RE: Lack of Response for Referrals Appalling
RE: Lack of Response for Referrals Appalling
Darren C Cargill, Family Physician/Specialist (Palliative Medicine), Medical Director, Hospice of Windsor and Essex County
Thank you to Dr. Neimanis et al. for their article on referrals and wait times.

I was appalled by the statistic that 36.4% of requests for consultation did not even receive a response.

I am the medical director for a hospice and community palliative care outreach program. We receive well over a hundred referrals every month. It is not uncommon to receive ten or more in a single day. These referrals come from FPs, NPs and specialists like oncologists, respirologists and cardiologists, just to name a few.

We follow the policy from the CPSO “Transitions in Care” (September 2019) which states:

17. Consultant physicians must acknowledge referrals in a timely manner, urgently if necessary, but no later than 14 days from the date of receipt.
18. When acknowledging the referral, consultant physicians must indicate to the referring health-care provider whether or not they are able to accept the referral.
a. If they are, consultant physicians must provide an anticipated wait time or an appointment date and time to the referring health-care provider. When providing an anticipated wait time, consultant physicians must follow-up once an appointment has been set.
b. If they are not, consultant physicians must communicate their reasons for declining the referral to the referring health-care provider.

Most often our response is a consult letter to the referring MD or NP as our wait time for new consults is less than 5 days (total, n...
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Thank you to Dr. Neimanis et al. for their article on referrals and wait times.

I was appalled by the statistic that 36.4% of requests for consultation did not even receive a response.

I am the medical director for a hospice and community palliative care outreach program. We receive well over a hundred referrals every month. It is not uncommon to receive ten or more in a single day. These referrals come from FPs, NPs and specialists like oncologists, respirologists and cardiologists, just to name a few.

We follow the policy from the CPSO “Transitions in Care” (September 2019) which states:

17. Consultant physicians must acknowledge referrals in a timely manner, urgently if necessary, but no later than 14 days from the date of receipt.
18. When acknowledging the referral, consultant physicians must indicate to the referring health-care provider whether or not they are able to accept the referral.
a. If they are, consultant physicians must provide an anticipated wait time or an appointment date and time to the referring health-care provider. When providing an anticipated wait time, consultant physicians must follow-up once an appointment has been set.
b. If they are not, consultant physicians must communicate their reasons for declining the referral to the referring health-care provider.

Most often our response is a consult letter to the referring MD or NP as our wait time for new consults is less than 5 days (total, not business days.) We offer same/next consults when contacted directly by a referring MD or NP.

Our wait time is kept low through a combination of real time triaging and centralized intake which distributes new referrals quickly and appropriately. All declined referrals are followed up in writing and a phone call to the referring provider with a suggestion for how best to redirect their request.

As both a focused practriced family physician and specialist, I would encourage all physicians who receive consult requets to review their process for receiving referral and show respect to our colleagues in primary care and, more importantly, patients. While many specialists can and do respond in a timely fashion, my hope is that a one-third non-response rate in this study is an anomaly.

Respectfully,
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Competing Interests: None declared.
Published on: (7 September 2017)
Page navigation anchor for RE: Referral processes and wait times in primary care
RE: Referral processes and wait times in primary care
Don Eby, MD, Grey Bruce Health Services
Neimanis et. al. report that 36% of all requests from primary care physicians for specialist consultation in Hamilton Ontario were not responded to by the end of their study’s follow up time of 5-7 week (1). This experience is likely mirrored, anecdotally, in many communities. Emergency physicians also make elective specialist referrals and run into similar problems. Furthermore, as an emergency physician, I often see people who come to the Emergency Department thinking they can work around the problems of non-response for a consultation or a prolonged wait for either a consultation or diagnostic procedure. As frustrating as these encounters are, these patients are simply trying to make an uncertain, unresponsive system work for them. Neimanis et. al. shed descriptive light on the problem of non-response to a request for consultation. However, most of the suggestions to solve the problem, including those from the CMA “toolkit” (2), are general and not helpful.

I use the following strategy to diminish non-response for an elective consultation from a specialist. When I make a referral, I write out the name of the specialist for the person and tell them that they should receive a call from the specialist’s office regarding an appointment time by a certain date (usually about 1 week). If they do not hear from the specialist’s office, they are to call the office and ask if the specialist received the referral. If the office did not receive the referral, the person phones...
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Neimanis et. al. report that 36% of all requests from primary care physicians for specialist consultation in Hamilton Ontario were not responded to by the end of their study’s follow up time of 5-7 week (1). This experience is likely mirrored, anecdotally, in many communities. Emergency physicians also make elective specialist referrals and run into similar problems. Furthermore, as an emergency physician, I often see people who come to the Emergency Department thinking they can work around the problems of non-response for a consultation or a prolonged wait for either a consultation or diagnostic procedure. As frustrating as these encounters are, these patients are simply trying to make an uncertain, unresponsive system work for them. Neimanis et. al. shed descriptive light on the problem of non-response to a request for consultation. However, most of the suggestions to solve the problem, including those from the CMA “toolkit” (2), are general and not helpful.

I use the following strategy to diminish non-response for an elective consultation from a specialist. When I make a referral, I write out the name of the specialist for the person and tell them that they should receive a call from the specialist’s office regarding an appointment time by a certain date (usually about 1 week). If they do not hear from the specialist’s office, they are to call the office and ask if the specialist received the referral. If the office did not receive the referral, the person phones the Emergency Department and asks for the referral letter to be FAXed again. If the specialist’s office acknowledges receipt of the referral, then the person should ask when the appointment is. If the consultation date has not been fixed, then they should ask by what date the specialist’s office will notify them about the consultation. If they have not heard by that date, phone again and go through the same procedure. I emphasize to be polite, but insistent in pinning down dates. They should try to be perceived as just seeking information they deserve to have. The squeaky wheel gets the grease.

Patients generally handle waiting for an appointment when they know when it will be. They can adjust their expectations or seek a referral to a different consultant if the wait time seems excessive. What is difficult and frustrating is the uncertainty of not knowing when or even if a consultation will be booked. I am amazed when I see people who tell me they were referred 6 months ago to someone, who’s name they never knew or have forgotten, and they have neither heard back from their family physician or the specialist about when the consultation will take place. Their faith in the system is touching but naïve. They patiently wait politely for a phone call that may never come.

Until patients and primary care physicians indicate that non-response to a request for consultation is unacceptable, we enabled this behavior to continue.

References

1. Neimanis I, Gaebel K, Dickson R, Levy R, Goebel C, Zizzo A, et al. Referral processes and wait times in primary care. Canadian Family Physician. 2017;63(August):619-24.

2. Canadian Medical Association. Referral and consultation process toolbox: Canadian Medical Association; 2016 [cited 2017 August, 23]. Available from: https://www.cma.ca/En/Pages/referrals-consultation.aspx.
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Competing Interests: None declared.