Referral coordination: From fragmentation to full-circle care

By Jonet Shepherd, Referral Coordinator at St. Luke’s Clinic – Easter Oregon Medical Associates in Baker City, OR. I joined St. Luke’s Clinic–Eastern Oregon Medical Associates about five and a half years ago. I started at the front desk, eventually moving into medical records and patient referrals, where I’ve been ever since. My job title in our clinic is ‘referral coordinator,’ but in the larger St. Luke’s system it’s ‘patient specialist.’ Tackling fragmentation My position evolved on our team because there was so much fragmentation: Patients would call us about their specialty appointments, and we couldn’t respond because we didn’t have the necessary info. I think every clinic would be wise, if they were truly patient-centered, to build referral management into the team. Some clinics have their RNs tackle referrals. I can’t imagine our nurses having the time it takes to create and follow up on referrals because they’re so actively involved in patient care. We needed better workflows, so we decided that having one person coordinate referrals made the most sense for our team. I get everything together from doc and specialist notes, labs, imaging—anything the next provider needs—and send it along so everything is in their hands before the patient shows up. Many physicians review the referrals to see if that patient is a good fit for them. We’ve had some docs say, “We would suggest this patient see this provider or that provider” or “This would be the best step,” or “We need this imaging first.” They dive in and are directing the flow of care prior to even seeing the patient. Bringing care full circle You have to have a plan for referrals: Is it just getting someone to the next step, or is it for the full loop of care? My job is to make sure the referral goes full circle so that providers have all the information on what’s happened and what needs to happen next. This helps us give the patient the best care experience. We can hold providers accountable for effective communication, which solved the fragmentation problem. Patients don’t seek health care to be told “I’m sorry, I can’t help you.” Our referral management system is patient-centered: Based on the information at hand, primary care can recommend going right to specialty care, if needed. Patients then don’t have to make time and spend money on care that’s unhelpful and maybe frustrating. Making a practical difference for patients I enjoy complexity more than the daily routine. Some patient situations require a lot of digging and persistence; other patients barely understand their health coverage. I help with both of these things. Maybe I like this work so much because I like putting puzzle pieces together. To accomplish something for the patient, whether it is through insurance or finding the right provider, seeing that the patient gets the best care—it’s almost like an adrenaline rush. It makes me feel good for them. Watch a short video on the four steps St. Luke’s took to establish the referral coordinator role. And stay tuned next week for part two of this two-part series: Jacque’s story on the evolution of team nursing at St. Luke’s. Jonet Shepherd is a member of the St. Luke’s Clinic – Eastern Oregon Medical Associates (EOMA) team in Baker City, OR. One of 30 clinics nationwide invited by the Robert Wood Johnson Foundation to participate in their best practices program, The Primary Care Team: Learning from Effective Ambulatory Practices (LEAP), EOMA was invited into LEAP as a result of their dramatic improvements in patient care. Ms. Shepherd’s work at St. Luke’s Clinic–EOMA is prominently featured in the LEAP Team Guide.

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