When Should You Refer?
Are you concerned about the loss of income for your practice when you send one of your clients to a referral hospital?
Have you or one of your clients ever had a negative experience associated with an emergency or specialty center? Do pet owners complain about having to go to a different practice for care or about the cost of a specialist? If you answered “yes” to any of these questions, you may think twice before you pick up the phone to refer a case. However, by focusing on patient advocacy, you’ll make the right decisions about when to refer.
Guiding Policies for When to Refer
A guiding principle in the referral process is for both primary care veterinarians and specialists to develop rapport and maintain effective communication protocols. Both parties need to take time to get to know one another and be willing to talk on the phone. Case discussions and collaboration will lead to better continuity of care and client service.
In addition, the following guiding policies can be used to make referral decisions:
• Ethics and standards of care. Adherence to professional ethics should guide decisions about whether referral to a specialty hospital is appropriate. Ethically, veterinarians must give clients honest assessments regarding their pets’ conditions and advise them of all their options for medical care. For example, it is always appropriate to inform clients about the availability of a boarded surgeon even when the referring veterinarian is confident about his or her surgical skills.
• Focus on patient advocacy. Be careful not to prejudge a client’s willingness or ability to pay for specialty care. Referral to a specialist should be discussed whenever appropriate, regardless of whether the general practitioner thinks the client might have financial constraints or be reluctant to agree to advanced diagnostics or treatment. It is often best to have clients call the specialty practice and get information about cost and payment options so the client can make the choice that best suits his or her needs. The use of third-party payment plans has helped increase the affordability of specialized care for many clients.
When Not to Refer
Sometimes a phone discussion with a specialist leads to the conclusion that a patient should not be referred. Or in another scenario, if it is clear that the pet owner absolutely doesn’t want further testing or surgery and this would be the only reason to see a specialist, then it doesn’t make sense to refer the case.
4 Criteria for When to Refer
Discuss the option of a referral with pet owners in the following situations:
1. For advanced diagnostic testing. This is a common reason for referral since most general practices don’t have advanced diagnostic testing capabilities such as MRI, CT, or endoscopy. Even for practices with ultrasound, it may be prudent to bring in a mobile specialist or refer more complicated cases because specialists usually have greater expertise in interpreting images.
2. When advanced surgery is indicated. If the pet needs, for example, orthopedic or soft tissue surgery that is not routinely performed at your practice.
3. Patient requires critical care/24-hour care. Patients that need fluids, medications, nursing care and evaluation around the clock need to be referred to an emergency or specialty hospital. Examples of these types of cases include ketoacidotic patients, patients with sepsis, postoperative patients, such as a gastric dilatation volvulus, pets needing transfusions, or puppies with parvovirus.
4. Complicated cases, patients don’t respond to treatment, or diagnosis is unclear. In these instances, it makes sense to refer a case or consult with specialists on the phone. Specialists may suggest further testing or treatment be done at the general practice prior to referral or they may confirm a referral is in the best interest of the pet. For example, an internist may recommend a low-profile feeding tube for cats with chronic renal failure that owners can use for 12 to 18 months to provide nutritional support, fluids, and medications. These feeding tubes are well tolerated and may significantly increase longevity and quality of life for the patient. In addition, liability may be a concern if clients find out there were other options that were not presented to them early on.
Three Ways Your Hospital Benefits from Referring
1. Enhanced client satisfaction. One of the most obvious yet often overlooked aspects of specialty referrals is increased client satisfaction and retention. Today’s pet owners are very bonded to their pets and trust general practitioners to provide excellent medical care including referrals to specialists when appropriate. Even if clients have cost constraints or decline a referral for other reasons, they appreciate that their family veterinarian cared enough about their pets to recommend the best available care for its current medical needs.
2. Increased patient care and longevity. Enhanced patient care translates to increased life spans for many pets. When pets live longer, referring veterinarians are rewarded emotionally and financially by having the opportunity to provide continued care for the pet. In human medicine, many studies show increased quantity and quality of life when peoples’ conditions are comanaged between the primary care doctor and specialist; this is true as well in veterinary medicine.
3. Increased revenues. Referring veterinarians who develop a positive relationship with area specialists find they frequently generate additional service revenue as a result of their collaborative relationship. Specialists often recommend procedures and diagnostics that can be performed prior to the referral as well as recommendations for rechecks and follow-up diagnostics that can be done at the general practice.
Treatments or procedures to do prior to referral include:
• Urinalysis with all diagnostic work-ups.
• Radiographs when referring patients for ultrasounds. Internists will want to review radiographs as well as ultrasounds when assessing patients.
• Set IV catheters and initiate fluids pending referral of critically
• Complete all diagnostics that are available and reasonable such as profiles, coagulation panels, blood pressures, endocrine testing, etc.
Changes in the veterinary profession in the past decade are viewed both negatively and positively depending on your perspective. Changes related to the increased specialization of veterinary medicine should be embraced as an opportunity to create a win/win scenario for general practitioners, specialists, and pet owners. The benefits of effective communication and collaboration between specialists and referring veterinarians include improved patient care and outcomes, improved financial success that results from a team approach to veterinary care, and strengthening of the human–animal bond for pet owners. | EVT
When Should You Refer?
Amanda L. Donnelly, DVM, MBA
1. AAHA Referral Guidelines:aahanet.org/Library/Referral.aspx
2. AAHA White Paper on Referral Issues: aldvet.com/wp-content/uploads/2010/04/FocusOnReferral1.pdf