Don’t drop the ball on patient referrals
Single-page form complies with JCAHO
It was a comment from the utilization review committee that might otherwise have gone unnoticed: Some patients were not getting the referrals they needed at Golden Rain Home Health in Walnut Creek, CA.
"They were finding people who might have needed to see a social worker, but nothing was triggering that referral," recalls Maureen Riley, RN, BSN, PHN, manager of improving organizational performance (IOP) at the agency.
But when the comment was made at a January meeting of the IOP steering committee, the group decided to act. The steering committee, which includes the agency director, the manager of clinical services, chart audit team members, and Riley, looks at problems as they arise, as well as regular agenda items raised by groups such as the utilization review committee.
The IOP committee acted quickly. Riley set up a quality improvement team, including someone from each service social work, physical, occupational, and speech therapies, nursing, and psychiatric care and immediately called a meeting.
There, Riley requested that each person look at what assessment information was required for a referral to be ordered. "We wanted to go to square one and see what diagnoses and assessments usually led to referrals," she says. Physical therapy, for example, said diagnoses that commonly led to a referral to their group included amputations or brain and spinal injuries.
To the common diagnoses were added some of the assessment situations that also spurred physical therapy involvement with a patient. Some of them included ambulation and gait difficulty, and transfer training.
Tool lists main categories
At the second meeting a week later, Riley asked the group to discuss what kind of format would make the information they had gathered most user-friendly. "If you have a new employee who is not familiar with something, then you want something simple that will allow them to see when a referral is called for."
The team took their long lists and simplified them. "We made a tool that listed the general categories, such as amputation not the specifics."
The tool has a spot for the caregiver to check whether a particular condition exists. (See copy of assessment tool, p. 91.) Even better, the simplification allowed all disciplines to be included on a single piece of paper. "The tool just lists the main categories. The notes can reflect more detail," says Riley. There is a longer guideline that provides details and allows staff to familiarize themselves with the specifics, but Riley says employees quickly learn the content and can use this one-page tool to order referrals.
The process wasn’t all simple, she admits. There were editing sessions and weekly discussions on differences between services. Referrals to physical and occupational therapy, for instance, often are triggered by the same or similar diagnoses. "We had the two groups talk about their differences," Riley says. Instead of emphasizing the similar diagnoses, the two services note their different focuses. For instance, both services might be working with a person with spinal injuries. But where physical therapy might be interested in bed mobility, occupational therapy is interested in the use of adaptive equipment. "The headings end up being very different, even when the diagnoses are the same," says Riley.
After about a month, the new tool was ready for introduction. First, Riley held inservices on the tool during regularly scheduled case conferences. "The staff seemed very receptive," she notes, although they initially balked at having to deal with one more piece of paper. "Once they looked at it, though, they liked it."
Currently, Golden Rain is in the middle of a 30-day pilot program for the tool. "The comments we are getting indicate this is very helpful for staff, but we don’t know how it will change our referral process yet."
One thing Riley is sure of is that it has improved communication and understanding between different teams, and that should help Golden Rain when it has a Joint Commission survey later in the year. "I know it fills not only our needs, but it meets its requirements for identifying a problem, setting criteria for solving it, and using teams of people who are end-users of the information to put the solution into place."
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