Direct Referral System Research Articles

809 Direct Referral Pilot- Speech and Language Therapy-ENT, Ninewells Hospital

Abstract Aim Ear, nose, and throat (ENT) specialists and speech and language therapists (SALT) work very closely together in management of speech and language disorders. Here at Ninewells Hospital, we have created a pilot project for a direct referral system, where voice referrals which have been vetted are referred directly to SALT, in which patients receive the necessary treatments and are then referred to ENT specialists if required. Method This is a retrospective audit. Patients who were referred directly to SALT were included in this study. A questionnaire was developed to assess patient’s satisfaction with this pathway via telephone. Five questions were asked about their satisfaction with different aspects of this study, including waiting times, concerns addressed, provided with clear explanations, patient involved in plans and overall satisfaction with ratings of between very good, good, fair, poor, very poor and prefer not to answer. Results 41 responses were obtained, out of 67 patients included in this study. Majority of patients responded with very good and good in all aspects of the questionnaire 48.8% had a very good overall satisfaction from this project. 29.3% had a good outcome and 4.9% responded with fair and poor respectively. Conclusions This study highlights that SALT play a significant role in not only improving quality of treatment for patients but also the quality of streamlining to specialist care as and when needed. More work is required to look into this pathway further and to assess its feasibility for implementation in the future and in other hospitals across the UK.

122 Head Injury discharge advice in an emergency department

BackgroundHead Injury (HI) is a common presentation to the Emergency Department (ED). Most injuries are mild and patients are often discharged directly from ED. However, persistent symptoms and failure to return-to-work are common. Comprehensive advice and a clear pathway if symptoms persist are critical to prevent unnecessary morbidity.ObjectivesTo audit the discharge advice and follow-up of patients discharged from an ED with a HI.MethodologyA Data Collection Tool was used to audit the advice and follow-up guidance given to patients attending St George’s Hospital ED in December 2018 with a HI. Data was audited against the NICE Guidelines for Head Injury: Assessment and Early Management (CG176).Results149 patients were identified. 41 (27.5%) were provided with written advice; 53 (35.6%) had no documentation of any HI advice being given; 55 (36.9%) had some documentation of HI advice but no documentation that written material was provided.ConclusionsA need for improvement in the quality of HI Discharge Advice from ED and access to spe- cialist HI outpatient assessment was identified. Improvements implemented included education of ED staff, new patient information sheet, and direct referral system to a specialist HI clinic. Re-audit is planned following these improvements.Samia.Elkommos@nhs.net

“One stop” clinic for upper gastrointestinal cancer—an alternative to “straight to test” referrals?

BackgroundPatients suspected to have upper gastrointestinal (UGI) cancer can be referred directly for investigation; however, at times this may result to inappropriate referrals. This study explores the model of a “one-stop” clinic as an alternative to the direct referral system. The current study aims to assess the feasibility and outcomes of a one-stop UGI clinic and evaluate sensitivity and specificity of “on-the-day” diagnoses.MethodsA retrospective analysis of case notes of patients seen in one-stop clinic, between January 2017 and January 2019, was conducted. All General Practitioner (GP) referrals were screened by a specialist nurse.ResultsAfter completion of the post-GP referral screening process, 252 patients (median age 68 years, IQR 58.8–77.3 years; M:F ratio 118:134) were allocated to the one-stop clinic. OGD was not required, contra-indicated or declined in 27 cases (10.7%). The records of three patients could not be found. One patient did not attend. Overall, 221 patients underwent testing and received “on-the-day” diagnoses. Sensitivity was 94% (range 87–100%), and specificity was 92% (88–96%). Ninety-six percent of patients received a diagnosis on the day.ConclusionsThe one-stop clinic was feasible and had good specificity and sensitivity. The finding of 10.7% of cases not being suitable for OGD indicates that a patient/specialist consultation is necessary to prevent misuse of endoscopy appointments. The authors recommend widespread adoption of one-stop clinics in UGI surgery.

Fostering Resilience in Pregnancy and Early Childhood During the COVID-19 Pandemic: The HUGS/Abrazos Program Design and Implementation

Pregnancy and early childhood pose unique sensitivity to stressors such as economic instability, poor mental health, and social inequities all of which have been magnified by the COVID-19 pandemic. In absence of protective buffers, prolonged exposure to excessive, early adversity can lead to poor health outcomes with significant impact lasting beyond the childhood years. Helping Us Grow Stronger (HUGS/Abrazos) is a community-based program, designed and launched at the time of the COVID-19 surge in the Spring of 2020, that combines emergency relief, patient navigation, and direct behavioral health support to foster family resilience and mitigate the negative impacts of COVID-related toxic stress on pregnant women and families with children under age 6. Through a targeted referral process, community health workers provide resource navigation for social needs, and a social worker provides behavioral health support. The use of innovative tools such as a centralized resource repository, community health workers with specialized knowledge in this age range, and a direct referral system seeks to assist in streamlining communication and ensuring delivery of quality care. We aim to serve over 300 families within the 1st year. The HUGS/Abrazos program aims to fill an important void by providing the necessary tools and interventions to support pregnant women and young families impacted by adversity exacerbated by the COVID-19 pandemic.

Implantable Cardioverter Defibrillator mHealth App for Physician Referrals and eHealth Education: ICD-TEACH Pilot Study.

BackgroundMobile health (mHealth) decision tools for implantable cardioverter defibrillator may increase physician knowledge and overall patient care.ObjectiveThe goals of the ICD-TEACH pilot study were to design a smartphone app or mHealth technology with a novel physician decision support algorithm, implement a direct referral mechanism for device implantation from the app, and assess its overall usability and feasibility with physicians involved in the care of patients with an implantable cardioverter defibrillator.MethodsThe initial design and development of the mHealth or smartphone app included strategic collaboration from an information technology company and key stakeholders including arrhythmia specialists (electrophysiologists), general cardiologists, and key members of the hospital administrative team. A convenience sampling method was used to recruit general internists or cardiologists that refer to our local tertiary care center. Physicians were asked to incorporate the mHealth app in daily clinical practice and avail the decision support algorithm and direct referral feature to the arrhythmia clinic. Feasibility assessment, in the form of a physician survey, was conducted after initial mHealth app use (within 3 months) addressing the physicians’ overall satisfaction with the app, compliance, and reason for noncompliance; usability assessment of the mHealth app was addressed in the physician survey for technical or hardware problems encountered while using the app and suggestions on improvement.ResultsA total of 17 physicians agreed to participate in the pilot study with 100% poststudy survey response rate. Physicians worked in an academic practice, which included both inpatient and ambulatory care. System Usability Scale was applied with an average score of 77 including the 17 participants (>68 points is above average). Regarding the novel physician decision support algorithm for implantable cardioverter defibrillator referral, 11% (1/9) strongly agreed and 78% (7/9) agreed that the algorithm for device eligibility was easy to use. Only 1 patient was referred through the direct referral system via the mHealth app during the pilot study of 3 months. Feasibility assessment showed that 46% (5/11) strongly agreed and 55% (6/11) agreed that the mHealth app would be utilized if integrated into an electronic medical record (EMR) where data are automatically sent to the referring arrhythmia clinic.ConclusionsThe ICD-TEACH pilot study revealed high usability features of a physician decision support algorithm; however, we received only 1 direct referral through our app despite supportive feedback. A specific reason from our physician survey included the lack of integration into an EMR. Future studies should continue to systematically evaluate smartphone apps in cardiology to assess usability, feasibility, and strategies to integrate into daily workflow.

Implementation of culturally targeted patient navigation system for screening colonoscopy in a direct referral system.

Low-income minorities often face system-based and personal barriers to screening colonoscopy (SC). Culturally targeted patient navigation (CTPN) programs employing professional navigators (Pro-PNs) or community-based peer navigators (Peer-PNs) can help overcome barriers but are not widely implemented. In East Harlem, NY, USA, where approximately half the residents participate in SC, 315 African American patients referred for SC at a primary care clinic with a Direct Endoscopic Referral System were recruited between May 2008 and May 2010. After medical clearance, 240 were randomized to receive CTPN delivered by a Pro-PN (n = 106) or Peer-PN (n = 134). Successful navigation was measured by SC adherence rate, patient satisfaction and navigator trust. Study enrollment was 91.4% with no significant differences in SC adherence rates between Pro-PN (80.0%) and Peer-PN (71.3%) (P = 0.178). Participants in both groups reported high levels of satisfaction and trust. These findings suggest that CTPN Pro-PN and Peer-PN programs are effective in this urban primary care setting. We detail how we recruited and trained navigators, how CTPN was implemented and provide a preliminary answer to our questions of the study aims: can peer navigators be as effective as professionals and what is the potential impact of patient navigation on screening adherence?

Efectividad de la implantación de un circuito rápido de consulta para el cáncer de pulmón

Objective To analyze the results obtained with a collaborative program involving primary care centers and their referral hospitals for the outpatient management of patients with suspected lung cancer. Material and method An observational, descriptive, cross-sectional study was conducted. From October 2002 to 2003, two primary care centers (urban and semi-urban) and the Pneumology service of a public hospital with 355 beds agreed to manage patients with suspected lung cancer on an outpatient basis. To do this, a direct referral system was designed. Results Twenty-four patients were referred to the hospital from primary care. Fifty percent of the patients met the criteria for direct referral and 46% showed radiological criteria. Seventy-nine percent of the patients did not provide the specific document designed for the rapid referral system by both healthcare levels. In 83% of the patients, the hospital sent a report to the primary care center. The number of admitted patients in diagnosis-related group (DRG) 082 decreased from 30 in the previous 3 years to nine in 2003. Despite this decrease, the mean length of hospital stay increased by almost 70% (10.1 vs 15.4 days). Conclusions Prioritizing outpatient management of suspected lung cancer increased the mean length of hospital stay. Despite this increase, the number of admissions for DRG 082 decreased. There is a wide margin for improvement in the direct referral system for the outpatient management of suspected lung cancer between primary and specialized care.

Better Outcomes in Mental Health Care: Impact of Different Models of Psychological Service Provision on Patient Outcomes

One hundred and eight Access to Allied Psychological Services projects have been funded under Australia's Better Outcomes in Mental Health Care programme since July 2001. All projects are run by Divisions of General Practice and enable general practitioners (GPs) to refer patients to allied health professionals for evidence-based care. They differ in the models they use to retain, locate and direct referrals to their allied health professionals. This paper examines the extent to which the projects are achieving positive patient outcomes, and explores the association between different models of service delivery and varying levels of patient outcomes. The paper draws on two data sources (a purpose-designed minimum dataset and a survey of models of service delivery) to examine the level of patient outcomes within and across projects, and variations in the level of patient outcomes by models of service delivery. The projects are achieving positive effects and these are mostly of large or medium magnitude. The projects do not differ markedly in terms of the patient outcomes they are achieving, despite differences in the models of service delivery they are using. However, those projects implementing a direct referral model, where the GP refers the patient directly to the allied health professional, have significantly greater effect sizes, indicating that they are achieving greater improvements in patient outcomes. In addition, there are non-significant trends toward direct employment of allied health professionals by Divisions being predictive of greater improvements in patient outcomes, and delivery of services from allied health professionals' own rooms being predictive of weaker patient outcomes. Overwhelmingly, the Access to Allied Psychological Services projects are having a positive impact for patients in terms of their level of functioning, severity of symptoms and/or quality of life. Preliminary indications suggest that a service delivery model incorporating the use of a direct referral system may be associated with superior outcomes. The findings are discussed in the light of the imminent listing of psychologists' services on the Medicare Benefits Schedule.

Mejora de la comunicación entre niveles asistenciales: derivación directa de pacientes a una consulta de alta resolución de cirugía mayor ambulatoria

To analyze the results obtained with a "one-stop" specialty service designed as part of a collaborative program involving primary and specialized care in order to improve communication between levels of care and reduce the delay in referral and surgical treatment for patients eligible for outpatient surgery. Prospective, descriptive, longitudinal study. Major Outpatient Surgery Unit of the Hospital Clinico San Carlos and health centers serving Health Area 7 in Madrid, central Spain. Patients more than 14 years of age with a surgical condition involving the abdominal wall, pilonidal sinus, soft-tissue tumor, or proctological disease. Direct referral, with completed preoperative work-up, of patients from health centers to the Major Outpatient Surgery Unit of the Hospital Clinico San Carlos according to a protocol developed by consensus. The patient is seen on the same day for surgical work-up and anesthesia work-up, and is given preoperative information. Patients then make only one further visit to the hospital to undergo surgery. Number of patients with each diagnosis referred, diagnostic concordance between the health center and hospital, delay from referral to surgical treatment, number of trips made for different appointments, and referral rate. A total of 188 patients were referred. More than two thirds (68.7%) had an abdominal wall condition eligible for direct referral. Diagnostic concordance was 96%. The delay from referral until surgery was reduced by 60%, and the number of trips for appointments was reduced by 66.6%. The overall referral rate was 12.6%. Because of its feasibility, acceptability, and cost-efficiency, the direct referral system has the potential to improve relations between primary and specialized care and enhance the quality of care by shortening the delay to treatment.

Use of the Judicial Section 9 Certification in the Free State

A direct referral system for referring persons who perpetrate a crime while suffering from a mental illness has evolved between the office of the Director of Public Prosecution (DPP) in the Free State, and the Free State Psychiatric Complex (FSPC) over the years. The efficiency and impact of this direct referral system have never been quantified. This study found that this alternative system is uncomplicated, functions quite effectively with a minimum of inappropriate referrals, and contributes greatly towards decreasing the workload of the judicial as well as the psychiatric system.

Bringing the mountain to Mohammed: a mobile dental team serves a community-based program for people with HIV/AIDS.

In spite of the direct referral system and family-centered model of primary oral health care linking medical and dental care providers, most HIV-positive patients at the Columbia Presbyterian Medical Center received only emergency and episodic dental care between 1993 and 1998. To improve access to dental care for HIV/AIDS patients, a mobile program, called WE CARE, was developed and colocated in community-based organizations serving HIV-infected people. WE CARE provided preventive, early intervention, and comprehensive oral health services to minorities, low-income women and children, homeless youths, gays and lesbians, transgender individuals, and victims of past abuse. More efforts to colocate dental services with HIV/AIDS care at community-based organizations are urgently needed.

Direct access day case oral surgery

To compare the effectiveness of direct access referrals with standard letter referrals, and also assess the impact of the direct access system on the primary care provider, secondary sector and from the patients perspective. Surgical and anaesthetic guidelines were agreed and 12 general dental practitioners were recruited to participate in the study. Each practitioner was given 100 envelopes which contained randomly allocated 50 direct and 50 standard referrals. For direct referrals, GDPs completed a pre-operative assessment and obtained an operation date by telephone from the day case unit while the patient was in the surgery. The clinical history sheet was faxed to the day unit and the radiographs posted. The only contact the patient had with the hospital was on the day of surgery. Standard referral patients were referred in the traditional way with a referral letter being sent to an out-patient clinic. Evaluation of the effectiveness of the direct referral system versus standard letter method were made via completion of questionnaires by the patients, dental practitioners, hospital clinicians, day case anaesthetist and co-ordinator. The study was carried out over 2 years commencing in 1997 at the Oral Surgery Day Case Unit at Manchester Royal Infirmary. A greater number of direct access referrals (409; 90%) were treated in comparison with (312; 75%) standard referrals (P < 0.001). Eighty nine per cent of direct access records were adequate pre-operatively. More than 70% of dentists and hospital clinicians preferred the direct access referral method. Sixty-three per cent of standard letter patients were satisfied with their mode of referral compared with 87% of direct access patients. Given appropriate guidelines dental practitioners are able to refer directly to oral surgery day case operation lists. This has proved to be the favoured method of referral for dental practitioners, the secondary sector and patients.

A study of the effectiveness of direct access day case oral surgery compared with standard letter referral

Objective To compare the effectiveness of direct access referrals with standard letter referrals, and also assess the impact of the direct access system on the primary care provider, secondary sector and from the patients perspective. Design Surgical and anaesthetic guidelines were agreed and 12 general dental practitioners were recruited to participate in the study. Each practitioner was given 100 envelopes which contained randomly allocated 50 direct and 50 standard referrals. For direct referrals, GDPs completed a pre-operative assessment and obtained an operation date by telephone from the day case unit while the patient was in the surgery. The clinical history sheet was faxed to the day unit and the radiographs posted. The only contact the patient had with the hospital was on the day of surgery. Standard referral patients were referred in the traditional way with a referral letter being sent to an out-patient clinic. Evaluation of the effectiveness of the direct referral system versus standard letter method were made via completion of questionnaires by the patients, dental practitioners, hospital clinicians, day case anaesthetist and co-ordinator. Setting The study was carried out over 2 years commencing in 1997 at the Oral Surgery Day Case Unit at Manchester Royal Infirmary. Results A greater number of direct access referrals (409; 90%) were treated in comparison with (312; 75%) standard referrals (P < 0.001). Eighty nine per cent of direct access records were adequate pre-operatively. More than 70% of dentists and hospital clinicians preferred the direct access referral method. Sixty-three per cent of standard letter patients were satisfied with their mode of referral compared with 87% of direct access patients. Conclusions Given appropriate guidelines dental practitioners are able to refer directly to oral surgery day case operation lists. This has proved to be the favoured method of referral for dental practitioners, the secondary sector and patients.

Direct referral hearing aid provision in the over sixties age group

A prospective study was designed in which General Practitioners were issued with a standard referral letter for hearing aid provision. Unknown to the General Practitioner an independent otolaryngologist assessment was obtained at the time of first attendance. Three hundred consecutive patients selected by General Practitioners applying these guidelines were seen in a designated hearing aid clinic staffed by audiological technicians of senior grade or above. Referral pro formata were incomplete in 75 patients who were not assessed. Ninety-four patients (31 per cent) (95 per cent confidence interval 29-36 per cent) were accepted by the audiologist. Obstructing wax was the most common criterion failed. Clinical agreement between audiologist and otolaryngologist was 57 per cent greater than chance. None of the cases of clinical disagreement altered treatment. A direct referral system as proposed could have processed only 31 per cent of 300 referrals. However, experienced technical staff reliably detected otological pathology and with aural toilet facilities 91 per cent of 225 patients (confidence interval 88-94 per cent) were aided.