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Takeaway: The referral coordination team in this sleep apnea study was linked to improved timeliness of specialist appointments, reduced reliance on community care services, and greater patient satisfaction, with favorable impacts on cost. In a recent survey, 81% of VA medical centers have now reported implementing referral coordination teams in at least three specialties.
Providing access to specialty care is a major challenge for large healthcare systems due to a shortage of available specialists. For example, approximately 1.3 million Veterans in the VA healthcare system suffer from obstructive sleep apnea and, overall, about 4.5 million are at high risk; however, there are only a little more than 300 VA providers specializing in sleep—a mismatch that reduces access. In 2018, the Office of Veterans Access to Care (OVAC) partnered with local providers at the VA Puget Sound Medical Center to pilot a referral coordination team for new referrals in sleep medicine in a way that maximizes workforce efficiency. From May 2018 through December 2019, a study led by Lucas Donovan, MD, MS, an HSR&D Career Development Awardee (CDA) and investigator with HSR&D’s Center of Innovation for Veteran-Centered and Value-Driven Care, utilized the referral coordination team in redesigning the initial sleep medicine consultation process by shifting the work from specialist providers (physicians and advanced practice providers) to registered nurses — and integrated administrative support staff within the team to increase service timeliness and continuity of care. Investigators then compared the referral coordination team and the traditional specialist-led method in terms of timeliness and community care referrals.
Findings showed that the referral coordination team was linked to improved timeliness of specialist appointments, reduced reliance on community care services, and greater patient satisfaction, with favorable impacts on cost. Patients whose consults had been completed by the referral coordination team were much more likely to have appointment dates within 28 days after referral than matched peers in the traditional system (33% vs. 12%) and to have these appointments scheduled within 7 days (35% vs. 7%). Further, each year, VA Puget Sound receives approximately 6,000 sleep medicine consults. Investigators estimate that the referral coordination team could allow VA Puget Sound to accommodate 4,800 additional visits, care valued at $420,368.
While timeliness is important, it is also crucial that patients are triaged to the proper services. In a subsequent evaluation, the team compared the receipt of potentially contraindicated sleep studies between patients managed by the referral coordination team or the traditional system. Patients referred for evaluation of obstructive sleep apnea by the referral coordination team were much less likely to receive sleep studies classified as potentially contraindicated according to recent guidelines. These results highlight the role of a referral coordination team in improving service quality.
Impacts
OVAC is working to disseminate this team-based model nationwide through the referral coordination initiative. In a recent survey, 81% of VA medical centers reported implementing referral coordination teams in at least three specialties.
Partners
VA’s Office of Veterans Access to Care (OVAC) spearheaded the development of referral coordination and supported this evaluation in partnership with HSR&D’s Center of Innovation for Veteran-Centered and Value-Driven Care, the VA Collaborative Evaluation Center, VA Puget Sound Health Care System, and VISN-20 Sleep Medicine.
Publications
Donovan L, Palen B, Fernandes L, et al. The Referral Coordination Team: A redesign of specialty care to enhance service delivery and value in sleep medicine. NEJM Catalyst: Innovations in Care Delivery. February 2021;2(2).
Donovan L, Palen B, Syed A, et al. Nurse-led triage of new sleep referrals is associated with lower risk of potentially contraindicated sleep testing: a retrospective cohort study. BMJ Quality and Safety. December 2020; Online ahead of print.
