Referral notes used as a tool for evaluating the co-operation between general practitioners and hospital physicians

Objective — To study what proportion of clinical visits to a general practitioner working at a Swedish health centre leads to a referral to a specialist, the adequacy of the reason for the referral, the quality of the referral notes, and the quality of the answers by the specialists to whom the patients had been referred.

Design -A referee committee representing the different medical specialists and the general practitioners studied all referral notes dealing with internal medicine, surgery, orthopaedics, and otorhinolaryngology during a defined period from two health centres as to adequacy of the reason for referral, the quality of the referral notes, and the quality of the answers to the referrals.

Setting and participants — Altogether 188 consecutive referral notes and 171 answers to these referrals from two Swedish health centres were evaluated.

Results — Of the visits to a general practitioner, 7–8% resulted in a referral to a hospital specialist, and 90% of these were answered by letter. The referee committee agreed that the vast majority of the reason for referral were adequate, and that the referral notes as well as the answers to these with few exceptions were adequately formulated.

Conclusions — The referrals from primary health care to different medical specialists worked adequately, but it was concluded that it may be further improved. When evaluating the co-operation between two medical systems, it is important that the evaluation as well is made in co-operation by representatives from the two systems.     

Comparison of integrated and consultation-liaison models for providing mental health care in general practice in New South Wales, Australia

Comparison of integrated and consultation-liaison models for providing mental health care in general practice in New South Wales, Australia The characteristics of a new service providing integrated mental health care in general practice are described and comparisons made with an earlier consultation-liaison (C-L) psychiatry service in general practice, including the range and severity of psychiatric problems, levels of general practitioner (GP) and psychiatrist involvement, and patterns of care. Clinical audit checklists were completed by two experienced mental health nurses for the first 100 patients referred to the service, which was conducted in conjunction with 8 general practices in the Port Stephens region of New South Wales, Australia. The mean age of the first 100 referrals was 38.05 years, 63.0% were female, and 55.0% were referred from GPs. Outcome measures included: referral information, patients' demographic and diagnostic characteristics, psychosocial functioning, psychotropic medication, management, and number of contacts with the mental health nurses. Relative to the earlier C-L psychiatry service in general practice, the integrated service treated a broader range of diagnostic groups with higher levels of disability. There were higher rates of mood (48.0%) and psychotic (20.0%) disorders and lower rates of adjustment (2.0%) disorders. One-third of patients were seen by an additional agency, other than the mental health nurses or GPs. Patients averaged 4.95 contacts with the mental health nurses, with marked variations according to diagnostic group. To date, the new service has been well received. It is highly accessible, acceptable to GPs and patients, caters for a broad range of psychopathology, including severe mental illness, and appears to be sufficiently versatile to be adaptable to a variety of treatment settings.     

Selective access: prioritizing referrals at the primary care/community mental health team interface

Objective: To examine how community psychiatric nurses (CPNs) in a nurse-led system for dealing with referrals to community mental health teams (CMHTs) from primary care prioritized referrals.Design: A retrospective survey of patients’ assessment records.Setting: Four CMHTs in Salford which provide specialist mental health care for the adult population (16–65 age group).Participants: A cohort of 874 patients referred by GPs and seen by CPNs for initial assessment.Measures: Referral outcome, demographic characteristics, general ICD-10 diagnosis and the Health of the Nation Outcome Scales.Results: Access to support appeared to be restricted to patients with diagnosable disorders, as opposed to sub-threshold problems of living. Three main factors were identified which explained how patients were prioritized: diagnosis; previous history; and the severity of their presenting problems.Conclusion: The findings suggested that providing a single gateway to the CMHT may help to clarify the referral process and help to manage the demand for care at the primary care/CMHT interface.     

Mental health problems of undocumented migrants in the Netherlands: A qualitative exploration of recognition,recording, and treatment by general practitioners

Objective. To explore the views and experiences of general practitioners (GPs) in relation to recognition, recording, and treatment of mental health problems of undocumented migrants (UMs), and to gain insight in the reasons for under-registration of mental health problems in the electronic medical records. Design. Qualitative study design with semi-structured interviews using a topic guide. Subjects and setting. Sixteen GPs in the Netherlands with clinical expertise in the care of UMs. Results. GPs recognized many mental health problems in UMs. Barriers that prevented them from recording these problems and from delivering appropriate care were their low consultation rates, physical presentation of mental health problems, high number of other problems, the UM’s lack of trust towards health care professionals, and cultural differences in health beliefs and language barriers. Referrals to mental health care organizations were often seen as problematic by GPs. To overcome these barriers, GPs provided personalized care as far as possible, referred to other primary care professionals such as social workers or mental health care nurses in their practice, and were a little less restrictive in prescribing psychotropics than guidelines recommended. Conclusions. GPs experienced a variety of barriers in engaging with UMs when identifying or suspecting mental health problems. This explains why there is a gap between the high recognition of mental health problems and the low recording of these problems in general practice files. It is recommended that GPs address mental health problems more actively, strive for continuity of care in order to gain trust of the UMs, and look for opportunities to provide mental care that is accessible and acceptable for UMs.     

The course of mental health problems in children presenting with abdominal pain in general practice

Abstract

Objective. To investigate the course of mental health problems in children presenting to general practice with abdominal pain and to evaluate the extent to which abdominal pain characteristics during follow-up predict the presence of mental health problems at 12 months’ follow-up. Design. A prospective cohort study with one-year follow-up. Setting. 53 general practices in the Netherlands, between May 2004 and March 2006. Subjects. 281 children aged 4–17 years. Main outcome measures. The presence of a depressive problem, an anxiety problem, and multiple non-specific somatic symptoms at follow-up and odds ratios of duration, frequency, and severity of abdominal pain with these mental health problems at follow-up. Results. A depressive problem persisted in 24/74 children (32.9%; 95% CI 22.3–44.9%), an anxiety problem in 13/43 (30.2%; 95% CI 17.2–46.1%) and the presence of multiple non-specific somatic symptoms in 75/170 children (44.1%; 95% CI 36.7–51.6%). None of the abdominal pain characteristics predicted a depressive or an anxiety problem at 12 months’ follow-up. More moments of moderate to severe abdominal pain predicted the presence of multiple non-specific somatic symptoms at follow-up. Conclusions. In one-third of the children presenting to general practice for abdominal pain, anxiety and depressive problems persist during one year of follow-up. Characteristics of the abdominal pain during the follow-up period do not predict anxiety or depressive problems after one-year follow-up. We recommend following over time children seen in primary care with abdominal pain.     

Neural Mobilization: A Systematic Review of Randomized Controlled Trials with an Analysis of Therapeutic Efficacy

Abstract

Objective

Each year our multidisciplinary outpatient clinic for patients with back pain receives a large number of referrals from primary care physicians, manual physiotherapists, and chiropractors. We wanted to assess the quality of the referrals regarding the information provided about case history, clinical findings, and results from additional investigations.

Material and methods

Two hundred and eighty six consecutive referrals received in the time period from 1 October 2008 to 1 March 2009 were reviewed. We investigated if the referrals contained 12 given items. The items were defined by consensus of the broad range of specialists working at the multidisciplinary outpatient clinic. All registered items were regarded as useful when assigning patients with a priority and appropriate caregiver at the outpatient clinic. The 12 items that our group felt were reflective of good referrals were information about occupational status, duration of symptoms, pain distribution, sensory symptoms, use of analgesics, alleviating and/or aggravating factors, systems enquiry (i.e. urination, bowel movements, and sleep), provided treatment, deep tendon reflexes, motor function, sensory examination, and radiculopathy tests (i.e. straight leg raise and/or foraminal compression test).

Results

Two hundred and fifty six (89·5%) referrals were from primary care physicians, and the remaining came from physicians in internships, manual physiotherapists, and chiropractors. Six (2·1%) referrals contained all 12 items. On average each referral contained 5·95 items (95% CI: 5·66–6·25). Information about analgesics, sensory symptoms, systems enquiry, and alleviating and aggravating factors was most frequently missing. Information about provided treatment, motor function, deep tendon reflexes, clinical tests, and occupational status was included in about half of the referrals. In 27·3% of the referrals from primary care physicians information about clinical findings was missing. Referrals from manual physiotherapists contained statistically significant more information (9·67 items, 95% CI: 7·63–11·70) than from the other groups (P<0·001). The number of patients registered with each primary care physician did not affect the number of items in the referrals.

Conclusion

Many of the referrals were inadequate. Inadequate referrals can lead to prolonged waiting time for examination and treatment. Referrals with relevant information about patient history and clinical findings are essential in order to assign patients with an appropriate caregiver at the outpatient clinic and to determine if and which diagnostic imaging findings are of clinical relevance.     

Outcomes of referrals from general practice

Objective - To investigate hospital referrals by general practitioners, subsequent hospital events, and discharge letters.

Design - Audit of 340 referrals written by 29 general practitioners, hospital case records, discharge letters, and primary care case records.

Setting - Salo Area Health Authority in southern Finland (population 43000).

Main outcome measures - Referral rates, reasons for referrals, distribution according to speciality, number of hospital days, visits to outpatient-departments, laboratory and radiological examinations, therapeutic procedures, changes in medication and/or diagnosis and availability of discharge letters.

Results - the mean referral rate was 4.5% and varied from 1.6-10.0 per cent. the referring physician's age, sex, and workload did not significantly explain the variation of referral rates between individual general practitioners. A third of all hospital referrals from general practitioners led to a single visit at the hospital outpatient department. Discharge letters were received for 33% of all referrals. A change in medication or diagnosis did not substantially affect the rate of discharge information supplied by the hospital.

Conclusions - the variation of the referral rates between the individual general practitioners was large. the small number of participating general practitioners (n=29) did not permit valid explanations for this variation. the referring general practitioner rarely receives discharge letters from secondary care providers.     

Uptake and Participation in Physical Activity Referral Schemes in the UK: An Investigation of Patients Referred with Mental Health Problems

The study compared outcomes of uptake, attendance, and completion between two patient groups (mental health, n = 134 and physical health, n = 2767) in a physical activity referral scheme in the UK during 2000 to 2003. Despite similar rates for the physical health and mental health groups for initial progression (94% vs. 90%), referral uptake (60% vs. 69%; p < 0.001) and programme completion (22% vs. 34%; p < 0.001) were significantly lower in the mental health referrals. In conclusion, physical activity referral schemes appear to be less well suited to the needs of the mental health patient. Further research is recommended.     

Referral timing of in-hospital cancer deaths to palliative care in a Saudi tertiary care hospital

Abstract

Introduction: Late referral of advanced cancer patients to palliative care adversely affects their end-of-life care. We conducted this study to determine the referral timing of in-hospital cancer deaths to palliative care in a Saudi tertiary care hospital.

Subjects and methods: A retrospective review of cancer referrals to palliative care during a 4-year period who eventually died in-hospital. The effect of different factors on referral timing was studied.

Results: From 1567 referrals, 887 (56.6%) were eligible. Referral during the last week of life occurred in 28% of cases. The median survival from the first referral was 19 days (95% CI, 16–22). In multivariate analysis, the survival differed significantly according to the referring specialty and the setting of referral (P = 0.002, and < 0.001; respectively). The survival was shorter for patients referred from the medical, haematology and paediatric oncology specialties and for those referred in the emergency room or while in-patients.

Conclusions: Referral of in-hospital cancer deaths to palliative care occurs late in our setting and many patients are referred when death is imminent. The identification of factors related to this late referral attitude may be helpful in future improvement of end-of-life cancer care. Further research is warranted to investigate other reasons that may lead to late referral and to find ways to improve referral timing.     

Retrospective analysis of physical therapy utilization by the specificity of the diagnosis and order written on the referral

Background: Arguments against reimbursement for direct access to physical therapy (PT) are that a physician examination is necessary to diagnose and that there is a potential for increased cost. Objective: To determine what percentage of PT referrals had a specific diagnosis and treatment orders. Additionally, specific and non-specific diagnoses and treatment orders were compared in regards to PT units billed, average visits per referral, and average cost per referral. Methods: The charts of 1,000 patients treated in outpatient PT underwent a retrospective chart review. Interferential statistics were used to determine if there was a statistically significant difference between specific and non-specific diagnoses and treatment orders in regard to PT units billed, average visits per referral, and average cost per referral. Results: Twenty-nine percent of all referring diagnoses were non-specific in nature and 58% contained treatment orders that were non-specific. Charts with a specific diagnosis had a statistically significant higher utilization as compared to non-specific diagnoses (p ≤ 0.001). Patients with a specific treatment order also displayed a statistically significant larger average in billed units, average visits per referral, and average reimbursement per referral than those without a specific treatment order (p ≤ 0.0001). Conclusion: Our findings suggest that a physician diagnosis and referral may not be required to direct care for patients seeking PT services. Third-party payers that require a physician referral for PT services may be delaying access to healthcare and increasing costs.     

Blood Pressure Screenings Through Community Nursing Health Fairs: Motivating Individuals to Seek Health Care Follow-Up

Purpose: To evaluate the effectiveness of blood pressure [BP] screenings through community-based health fairs. Effectiveness was measured by those with high BP readings who either made an appointment with or actually followed up with their primary care provider [PCP] in person following post-screening referral. Data sources: Anonymized data were provided for 958 individuals who obtained BP screening through a three-day health fair provided by the Ceres Police Department Nurse Program. Conclusions: Of 958 screened, 170 (17.8%) were identified with high BP readings and provided with PCP referral. Data were analyzed on 124 individuals with high BP recordings. Of the 124 PCP referrals, 116 (93%) either made an appointment with or followed up in person with their PCP following BP screening. Of the 98 who visited with their PCP, 29 (30%) were either placed on BP medication, had their current BP medication dose increased, or were changed to another BP medication by their PCP. Implications for Practice: Hypertension remains a leading cause of morbidity and mortality. Nurse-operated health fairs, crafted to identify those with high BP readings, are promising as a simple and effective means in motivating individuals to seek follow-up care.     

Implementing a Safety Bundle to Improve Screening and Care for Perinatal Mood and Anxiety Disorders

ObjectiveTo improve screening and care of individuals with perinatal mood and anxiety disorders (PMAD) through the implementation of a perinatal mental health safety bundle.DesignRapid-cycle quality improvement model using four plan–do–study–act cycles over the course of 90 days. Individuals between 28 and 32 weeks gestation and at their 6-week postpartum follow-up visit were screened and offered stage-based care for PMAD.Setting/Local ProblemAt baseline, only 15% of clients of a suburban, private-practice women’s health clinic were receiving PMAD screening with a validated tool, and the site lacked standardized PMAD care practices among health care providers.ParticipantsHealth care providers (n = 2), staff (n = 4), and eligible patients (n = 78) at a private-practice women’s health clinic.Intervention/MeasurementsA screening, brief intervention, referral, and treatment/follow-up (SBIRT) model was used to screen eligible patients, provide treatment options, and appropriately refer for follow-up to mental health services. Team engagement occurred via weekly meetings. Measurements included pre–post maternal and team engagement survey results, biweekly chart review, and run chart analysis.ResultsEffective PMAD screening and right care were achieved for 85% of eligible individuals; this included receiving screening, referral to treatment, a scheduled mental health appointment, and clinic follow-up to ensure mental health care uptake.ConclusionUse of the SBIRT model to implement a safety bundle may contribute to improved mental health outcomes for individuals receiving perinatal care in a private-practice outpatient health care setting. Education and engagement among clinicians, staff, and patients are key to successful implementation of a safety bundle.     

A Pilot Project to Investigate Radiation Therapist Referrals to an Ad Hoc Supportive Care Oncology Clinic

Purpose/Aim

Approximately 400 patients are treated daily within the radiation therapy (XRT) department at the cancer centre where this project took place. As part of their clinical interactions during the treatment delivery process, radiation therapists (MRTs) may refer patients to a third party “RN Assessment Office” for non technical issues. These referrals can result in extended wait times for patients as well as disruptions to the scheduling of MRTs and other health care professionals. This review aimed to identify issues that resulted in third party referrals by MRTs. Data collected may enable insight into the issues that prompt third party referrals and help support MRTs in managing patient issues that are within their scope of practice.

Managed health plan effects on the specialty referral process: results from the Ambulatory Sentinel Practice Network referral study

OBJECTIVES: The specialty referral process is one of the chief targets of managed care constraints on ambulatory medical decision-making. This study examines the influence of gatekeeping arrangements and capitated primary care physician (PCP) payment on the specialty referral process in primary care settings. RESEARCH DESIGN: Primary care practice-based study of referred and nonreferred office visits. SUBJECTS: The study comprised 14,709 visits made by privately insured, nonelderly patients who were seen by 139 primary care physicians in 80 practices located in 31 states. MEASURES: Visits were grouped by health plan type: gatekeeping with capitated PCP payment; gatekeeping with fee-for-service PCP payment; no gatekeeping. Dependent measures included the proportion of visits referred, characteristics of referrals, and physician coordination activities. RESULTS: The percentages of office visits resulting in a referral were similar between the two gatekeeping groups and higher than the no gatekeeping group. Patients in plans with capitated PCP payment were more likely to be referred for discretionary indications than those in nongatekeeping plans (15.5% v 9.9%, P < 0.05). The frequency of referring physician coordination activities did not vary by health plan type. The proportion of patients in gatekeeping health plans within a practice was directly related to employing staff as referral coordinators, allowing nurses to refer without physician consultation, and permitting patients to request referrals by leaving recorded telephone messages. CONCLUSION: The specialty referral process for privately insured nonelderly patients enrolled in managed health plans is generally similar, regardless of the presence of gatekeeping arrangements and capitated PCP payment. An increase in the number of discretionary referrals among patients in plans with capitated PCP payment provides support for exploring strategies that encourage PCPs to manage in their entirety conditions that straddle the boundaries between primary and specialty care. In response to increasing numbers of patients enrolled in managed health plans with gatekeeping arrangements, physicians appear to modify the structure of their practices to facilitate access to and coordination of referrals.     

Kommunikation und Befundaustausch zwischen Hausärzten und Orthopäden bei Rückenschmerzen

Introduction

Low back pain is a frequent reason for consultation in general practice. Many patients are treated in cooperation with an orthopaedic surgeon which requires an effective exchange of information. The aim of this study was to investigate the level of communication between general practitioners (GPs) and orthopaedic surgeons.

Material and methods

In this retrospective observational study referrals from GPs and corresponding response letters from orthopaedic surgeons were analyzed. GPs were asked to provide reasons for referral and to rate the quality of the response letters.

Results

A total of 12 out of 82 GPs from the teaching network of the Medical School of Göttingen participated in the study. Of 911 referrals to ambulatory orthopaedic surgeons within 3 months, 34% (n=312) were referred for low back pain. GPs provided little information beyond a diagnosis on the referral contrary to their self-perception. Most referrals (61%) were initiated by patients and most of them were considered at risk for chronification (72%) by the referring GP. Despite a formal obligation to report back, GPs received a response letter for only one-third (114/312) of the patients. GPs rated most of them as satisfactory, however, 59% were unsatisfied with the treatment recommendations. Only 10% of the letters contained psychosocial details. The information provided in the orthopaedic response letters was heterogeneous and only partly fulfilled the criteria set by the Interdisciplinary Society for Orthopaedic Pain Management.

Conclusion

Incomplete and scant information on referral forms from GPs and a high non-response rate from orthopaedic surgeons suggest that current health care system and referral forms do not promote effective communication about the patient. This might explain the satisfaction of GPs with the orthopaedic response letters despite the lack of information. The GPs dissatisfaction with the treatment recommendations reflects the limited treatment options for chronic low back pain in ambulatory care.     

Improving mental health service users' physical health through medication monitoring: a literature review

nash m . (2011) Journal of Nursing Management  19, 360–365
Improving mental health service users’ physical health through medication monitoring: a literature review Aim To explore the importance of improving physical health in mental health service users through medication monitoring. Background Mental health service users’ physical health is frequently poor, although many have contact with health-care services. Adverse drug reactions are a unique risk factor for poor physical health. However, medication monitoring remains inconsistent. Evaluation A literature review was conducted using search terms: medication monitoring, adverse drug reactions, physical health/illness, mental health/psychiatric nursing. Databases searched included PsychINFO, Pubmed, CINHAL and the British Nursing Index. Key issue Structured medication monitoring is required to enhance physical health and reduce the risk of adverse events. Implications for nursing management Nurse managers should promote a culture of evidence-based practice in medication monitoring. Practitioner learning needs and competencies should be assessed to provide relevant education and skills training. Conclusion Nurse managers require strategic leadership to transform practice and enhance mental health service users’ physical health through medication monitoring. Good practice guidelines should be implemented to improve quality of care and reduce the risk of adverse events. Addition to current knowledge This paper illustrates the importance of medication monitoring in improving physical health.