Piedmont Access to Health Services

Piedmont Access to Health Services

Policy Number: 01-06-001

SUBJECT: PATHS Community Medical Centers Specialty Consult, Diagnostic testing/ X-ray Order Referral Policy

EFFECTIVE DATE: 10/15/09

REVIEWED/REVISED: 03/30/2010, 06/27/2011, 03/29/2012, 12/03/2012 ______

Policy: PATHS Community Medical Centers are committed to providing high quality and comprehensive primary medical care. In some cases, it is important that patient’s be evaluated for treatment by providers that specialize in certain kinds of medicine in order to ensure that the patient achieves the best clinical outcome possible. In those instances, PATHS will refer patients to the most appropriate facility and/or provider. Understanding the importance of continuity of care and out of commitment to patients to be a true primary care home, PATHS will make every effort to ensure that the patient’s are complete and thorough by way of including all consult notes and test results.

Procedure:

1.  Generating Referrals:

a.  All patients will be evaluated by a primary care provider at one of PATHS Community Medical Center sites. If the primary care provider determines that a specialty consult referral is clinically appropriate, such will be noted in eClinicalWorks (eCW) by generating an “Outgoing Referral”. (Detailed instruction for how to generate an outgoing referral is available by contacting PATHS’ IT Department).

b.  Only PATHS’ medical providers should generate referrals according to the limitations of their licensure (if applicable). Any midlevel provider deeming it appropriate to generate a referral for a provider that exceeds the limitations of their licensure, should do so in consult with their assigned supervising physician.

c.  The referral should be completed with as much information possible, but must include the following at a minimum:

i.  Patient’s Name;

ii. Referral date (the date the referral was generated);

iii.  Start Date (the date that provider would like the referral to begin being worked on; example: a follow-up mammogram may have a start date for 3 – 6 months in the future.)

iv.  Specialty;

v. Priority

vi.  Reason;

vii.  Specific Diagnosis Code, with as much detail as possible;

viii.  Assignment to the appropriate person or heading; and

ix.  Comments regarding financial aid paperwork (if appropriate).

d.  PATHS’ providers should generate a separate referral for each specialty consult needed.

e.  Priority statuses should be assigned as follows:

i.  “Routine” = Referrals that are clinically appropriate for the patient that can be scheduled as soon as possible, but do not require immediate attention.

ii. “Urgent” = Referrals that are clinically appropriate and require follow-up attention within 14 business days from the date the referral was generated.

iii.  “Stat” = Referrals that require immediate specialty consult.

f.  Referrals should be assigned as follows:

i.  For Routine and Urgent referrals:

1.  If the patient is does not have medical insurance, the referral should be assigned to “UNINSURED REFERRAL”.

2.  If the patient has insurance, the provider should assign the referral to designated front desk staff member.

ii. For Stat referrals, regardless of insurance status, the referral should be assigned to the nurse working with the provider on the day the referral was made.

g.  If the patient being referred is uninsured and is being evaluated during a face to face visit, the provider (or his/her nurse) should immediately give the patient financial screening applications for UVA Health System and/or Carillion Health System, and instruct the patient to complete and submit the screening application to the appropriate facility as soon as possible, as their appointments will not be able to be scheduled until they have been approved for financial assistance. The provider should note “UVA/Carillion financial aid app given and patient instructed to complete and submit” on the referral screen on the Notes tab.

2.  Processing Referrals:

a.  General Expectations:

i.  All referrals, regardless of priority, will begin being processed within one business day of having been generated.

ii. “Stat” referrals will be completed the same day they are generated, or no later than the next business day. Every effort will be made to get the consult appointment scheduled before the patient leaves, should the patient be in the office for a face-to-face visit.

iii.  Urgent referrals will be completed within 5 business days of having been generated.

iv.  Routine referrals will be completed as soon as possible, and will vary based on the complexity of the referral and the processes required to complete by the specialty provider/facility accepting the referral.

v. PATHS’ nursing staff will be responsible for overseeing the referral process for all Stat referrals.

vi.  PATHS’ Patient Navigators will be responsible for overseeing the referral process for all urgent and routine referrals for uninsured patients.

vii.  PATHS’ front desk staff will be responsible for overseeing the referral process for all urgent and routine referrals for insured patients.

viii.  PATHS’ Patient Navigators will maintain expert knowledge on all community resources and referral providers/facilities to serve as advisors to other PATHS’ staff members who assist in the referral process.

ix.  Referrals that cannot be completed by the expectations established in sections ii – iv of this section will be assigned back to the referring provider, with clear documentation of the steps taken so far and the barriers encountered so that appropriate next steps can be determined.

b.  Processing Referral Appointments:

i.  PATHS’ Patient Navigators, nursing staff and front desk staff will routinely check for stat referrals throughout the day by monitoring the referral ‘jelly bean’ in eCW.

ii. PATHS’ Patient Navigators, nursing staff and front desk staff will maintain up-to-date knowledge of community resources and the steps necessary to complete referrals. While there are exceptions, generally stat referrals will be related to diagnostic imaging or x-ray studies, while urgent and routine referrals will have a much larger scope. Any time there is a question as to which resource would be best suited to meet the patient’s need, the nursing staff should consult with the referring provider, as well as the Patient Navigator staff.

iii.  The person who opens a referral for the first time, and begins working on it, will assign the referral to themselves in eCW.

iv.  All steps taken in the process of securing the appointment with the consulting specialist and/or facility will be documented under the notes tab of the referral screen in eCW.

v. Special attention will be paid to the “start date” indicated on all referrals. This is the date that PATHS’ Patient Navigators should start working on setting up the referral, as deemed appropriate by the medical provider that generated the referral.

vi.  The status of any urgent and routine appointments should be updated as follows:

1.  All referrals will remain “Open” until an appointment has been secured for the patient. During this time, other status updates should be applied to monitor the progress of completing the referral as follows:

a.  Pending Patient Response: This would apply to situations requiring the patient to contact PATHS in response to a phone call or other inquiry.

b.  Pending Financial Screening: Applies to situations where the patient needs to complete a financial screening process directly with the facility/provider to which they are being referred. This is most often applied in cases where the patient is being referred to UVA.

c.  Pending Appointment: Applies when the financial screening process is complete, and when all records have been forwarded to the specialty provider/facility for review, or when the patient has been put on a waiting list for an appointment by the provider/facility accepting the referral.

d.  Pending Insurance Authorization: Applies when the patient’s insurance requires that the referral be authorized. This status would be applied after the authorization request has been submitted.

2.  Once the appointment has been scheduled, the status will be updated to “Consult Pending”, and “Appointment Scheduled; Pending Notes”. The appointment date and time, as well as the “Referral To Provider” should be selected on the referral screen in eCW. PATHS will notify the patient via telephone and/or letter of the appointment date and time, driving directions to the facility, and the contact information of the scheduling department of the provider/facility accepting the referral, so that the patient can contact the provider/facility directly should the appointment need to be rescheduled.

3.  In many cases, local care may not be available for uninsured patients, resulting in University of Virginia Health System (UVA) or Carilion Health System being the only two viable options. A list of phone and fax numbers is being provided for each of these facilities as Attachment 1 with this policy.

3.  Referral Appointment Follow-up:

a.  Once per week, PATHS staff will review the list of Pending Appointments under the eCW Referral ‘jelly bean’ for the following and investigate any appointment ate that is over one week old.

b.  Confirm that the report (diagnostic test or x-ray) and/or consult note has been received from the specialist/facility to which the patient was referred by reviewing the “Patient Docs” icon on the patient’s hub in eCW.

i.  If the report and/or consult note is present in the patient chart, notate such in the “Notes” section of the referral and update the appointment status to “Addressed”.

ii. If the report and/or consult note is not present, contact the specialist/facility to which the patient was referred and request the report and/or consult note, and include the name of the individual with who you spoke and the details of the conversation in the “Notes” section of the referral. Leave this referral status as “Consult Pending” for continued follow-up.

iii.  If the specialist/facility reports that the patient rescheduled the appointment, update the appointment details on the referral screen in eCW.

iv.  If the specialist/facility reports that the patient cancelled without rescheduling, or did not show up for the appointment, send the patient a letter that will include the contact information for the schedule department of the specialist/facility to which they are being referred with instruction to a) call and reschedule the appointment, and to b) contact PATHS with the details of the newly scheduled appointment. The letter should clearly state that this is the only notice they will receive on this issue.

1.  If the patient contacts PATHS, the new appointment information should be updated on the referral screen in eCW.

2.  If the patient does not contact PATHS, refer to and follow the steps outlined in this policy, section 4, item c of this policy.

4.  Special Considerations:

a.  Due to the high volume of patients treated by PATHS’ Community Medical Centers, it is important that PATHS’ staff work efficiently. If two attempts to reach a patient by phone have failed, the patient should be contacted via letter, requesting that they follow-up within 5 business days of having received the letter. A copy of this letter should be scanned into the patient’s eCW record, and a notation of such should be documented in the “Notes” section of eCW.

b.  If the patient fails to respond to the first letter, a second letter should be sent. This letter should clearly notify the patient that failure to respond will result in PATHS assuming that they are unwilling to comply with the referral. A response should be requested within 5 days of the patient having received the letter. A copy of this letter should be scanned into the patient’s eCW record, and a notation of such should be documented in the “Notes” section of eCW.

c.  If the patient fails to respond to the second notice, such should be noted in eCW, and the status of the referral should be updated to “Addressed”. A telephone encounter should be generated and directed to the provider who generated the referral, referencing the specific referral (provide the patient name, specialty to which they were being referred, and the date of the referral) for a review of the patients overall compliance.

Signatures:

______

Chief Executive Officer Date

______

Chief Operations Officer Date

Attachment 1:

UVA Phone and Fax Numbers

·  Breast Center 434-924-2625 Fax: 434-982-6534

·  Cardiology- 434-243-1000 Fax: 434-244-7564 (fax stress test to 434-244-7551)

·  Dermatology- 434-924-5115 Fax: 434-243-9479

·  Endocrinology- 434-924-1825 Fax: 434-924-9616

·  Gastroenterology- 434-924-2959 Fax: 434-924-0491

·  General Surgery 434-243-4811 Fax: 434-243-7272

·  Hematology- 434-924-5226 Fax: 434-243-6086 (Ask for Jennifer, need to fax notes to get appt first)

·  Hepatology- 434-924-2626 Fax: 434-924-0491

·  ID/Wound Care Clinic (Attn: Bridget) 434-982-1700 Fax: 434-982-3268

·  Nephrology- 434-924-1984 Fax: 434-243-6284

·  Neurology- 434-924-5304 Fax: 434-982-1850

·  Neuro Muscular- 434-982-6551 Fax: 434-924-9068

·  Neuro Surgery- 434-924-2203 Fax: 434-243-2954

·  OBGYN- 434-924-1955 Fax: 434-982-1841 (Colposcopy clinic phone # is 434-924-5295)

·  Ophthalmology- 434-924-5485 Fax: 434-924-5180

·  Orthopedics- 434-243-5432 Fax: 434-243-0290 (Sports Medicine Clinic phone # is 434-243-7778)

·  Otolaryngology- 434-924-2153 Fax: 434-924-1736 (Attn: Debbie)

·  Pain Management- 434-243-5676 Fax: 434-243-5689

·  Plastic Surgery- 434-924-5078

·  Pulmonary- 434-924-5219 Fax: 434-924-9720

·  Psychiatry- 434-924-5457 Fax: 434-982-1572

·  Rheumatology- 434-243-0223 Fax: 434-243-0239

·  Spine Center- 434-243-3633 Fax: 434-243-1538

·  Telemedicine- 434-982-3756 Fax: 434-244-7521

·  Urology- 434-924-2224 Fax: 434-982-3652

Carilion Clinic Phone and Fax Numbers

·  Carilion Clinic Cardiology (Martinsville) 276-634-4400 Fax: 276-638-2900

·  Carilion Clinic Cardiology (Roanoke) 540-224-1041 Fax: 540-857-5295 (requires referral form)

·  Carilion Clinic Podiatry (Rocky Mount) 540-489-4541 Fax: 540-483-4128

·  Carilion Franklin Memorial Hospital (Rocky Mount) (Radiology only) 540-489-6440Fax: 540-489-6369

·  Carilion Clinic (Radiology-Roanoke) 540-853-0756 Fax: 540-857-5302

·  Carilion OB/GYN Clinic (Rocky Mount) 540-484-4836 Fax: 540-484-4837

·  Carilion OB/GYN (Roanoke) 540-985-9862 Fax: 540-985-9890

·  Carilion ENT (Roanoke) 540-581-0180 Fax: 540-343-0495

·  Carilion General Surgery (Roanoke)- 540-224-5170 Fax: 540-983-8212

·  Carilion Neurology (Roanoke) 540-224-5170 Fax: 540-982-3434 “Attn: Michelle Bailey”

·  Carilion Pulmonary/Sleep Clinic (Roanoke) 540-985-8505 Fax: 540-344-3313