Family medicine practices are the “home” for most of our patients' health care needs. Sometimes, of course, our patients need the expertise of more specialized physicians, which means sending our patients out into the wider “medical neighborhood.” This journey can be risky because of the lack of coordination among the fragmented medical team. This often results in duplicative tests, unnecessary treatments, and conflicting recommendations between one physician and another.

As our patients' family physicians, it is our responsibility to ensure that they have coordinated care when we provide referrals so that they receive efficient, high-quality medical treatment and seamless transitions of care. This is an important role for family physicians, whether we practice in a free-standing primary care group referring to the consultants across town, as I do, or as part of a large health care organization referring to the consultants down the hall. The issues that occur between family physicians and consultants are largely the same.

For the past 10 years, our practice has used service agreements to facilitate the complex relationships between family physicians and consultants. A service agreement is a written document — not a contract — negotiated between the primary care practice and an individual consulting specialty practice that defines the expectations of referrals between the two offices and clarifies common issues such as urgent access to the consultant and timely exchange of information. This article will discuss why these agreements are helpful and how to develop them for your practice.

THE WARM HANDOFF

The goal of the service agreement is to create a “warm handoff” between the family physician and the consultant. Both the patient and the family physician benefit from this, because a warm handoff reinforces the patient's trust in our judgment, helps build the patient's relationship with the new physician, and sets the stage for more effective care.

There are three key elements to ensure a warm handoff for every referral:

1. Collegial relationships. Given physicians' busy schedules, informal peer-to-peer discussions about individual patients are not always possible. But the potential for conversation between the primary care physician and the consultant should always exist — especially when the patient has a complicated history or condition.

2. Information transfer. The two sides must establish a consistent and easy way to provide the correct and most relevant patient data to one another in a timely way.

3. Support system. Whether they're called care coordinators, referral specialists, or simply front-office staff in a small practice, those personnel who help facilitate the referral process must be aware of the service agreements. Without an organized support system, including staff who know what information to send and when to send it, the entire process can unravel. This requires initial attention but simplifies the process in the long run.

COMMON CONCERNS ABOUT REFERRALS

Service agreements should grow out of discussions between physicians, not with a practice manager or referral coordinator of a hospital or large health group. One goal of the service agreement is to facilitate critical conversations between the referring and the consulting physicians in order to agree on mutual expectations. This can't happen using a go-between.

Before you sit down with your consultants to create service agreements, it can be helpful to think about the challenges of referrals and what needs to be improved. Here are some common areas of concern for family physicians:

• Urgent or semi-urgent access. Both of the orthopedic offices we refer patients to have given us a special phone extension answered by a nurse who will either triage the patient into the schedule or get the orthopedist on the phone for a direct discussion of an urgent problem. This has saved our patients numerous expensive emergency room (ER) visits because we are no longer told to “send them to the ER, and I'll see them in follow-up.”

• Availability of lab or imaging results. In our practice, if the consultant includes the family physician on the order form, the patient's results are sent to our electronic health record (EHR). If the consultant simply sends us copies attached to the consult note, we have to manually enter and scan the results.

• Further referrals. Consultants may sometimes need to call in other specialists. For example, a cardiologist who determines that a patient is anemic might send him or her to a hematologist or gastroenterologist. This can be a problem if the referral is done without your knowledge, because you likely want to choose your own specialist, you may have the expertise to evaluate the patient yourself for the newly discovered problem, or you may know that the patient has already been evaluated for that issue and doesn't need further workup.

• When to return the patient. Does the cardiologist manage stable atrial fibrillation forever, or is the patient returned to the family medicine practice with the understanding that the family physician will manage care going forward? When we initiated a service agreement with our cardiologists, we agreed that with a-fib the cardiologist would leave it to the family physician to handle anticoagulation because we were usually seeing the patient anyway for other medical concerns, such as diabetes or chronic obstructive pulmonary disease. The cardiologist acts as a consultant on the complex problem, and we continue in our role as primary manager of the patient's chronic conditions.

Consulting specialists we speak with say service agreements also give them an opportunity to raise concerns they have with the primary care physicians sending them patients. Consultants often won't raise these issues by themselves because they rely on our referrals and are afraid of offending us. By negotiating these agreements as a group, however, you can depersonalize the conversation.

The three main concerns we heard from specialists were the following:

• Desired action. Consultants said they needed to know exactly what the primary care physician wanted them to do. For example, if an orthopedist is referred a patient with knee pain, does the referring physician want the orthopedist to diagnose the patient and send him or her back for treatment or go ahead and manage the problem?

• Availability of information. With EHRs, referring physicians sometimes send consultants a single note that is several pages long and full of information that has no bearing on the problem at hand. For instance, the information may be from the most recent office visit, but the referral might relate to a medical issue that surfaced one or two visits ago.

• Physician responsibility. Consultants may be uncomfortable diagnosing or treating patients and then sending them back to the family physician for ongoing treatment or follow-up due to fear that they will be liable if something goes wrong. A common example is treated breast or prostate cancer that needs ongoing monitoring. Our malpractice insurer's position is that if you hand off the patient to another physician and that physician accepts the handoff, you are no longer liable. You may need to seek a similar opinion.

STARTING THE CONVERSATION

To begin the process of creating a service agreement, the physicians in your practice first need to determine if they can agree on a somewhat unified approach to referrals. This can be difficult because individual physicians' referral patterns can differ widely, along with their willingness to closely manage certain conditions. Assuming you can reach consensus, contact a consultant practice you use frequently or have had good experiences with in the past, and ask if they are willing to meet. While the discussion will be between physicians, it may be helpful to bring along a practice manager or other person who can help write down the key points of the agreement and make it part of your practice work flow.

It is helpful to go into that meeting with a service agreement template. (See “Service agreement template.”) If you just say you want to create a “service agreement,” many people may not know what you are talking about. A template gives you a list of topics to discuss, such as the following:

• How do your patients access the consultant's practice, not only for urgent and semi-urgent care but for more routine care as well? This would also be a good time to find out which insurers the consultant does not work with or if he or she sees only patients in certain age groups.

• What information does the consulting specialist need from your practice to move ahead with the consultation, and what information do you need to receive back from the consultant? To improve efficiency, it also helps to know if there are tests or other treatments the consultant requires before seeing a patient for the first time. If your practice and the consultant's practice use different EHRs, you will also need to see if they can communicate and, if not, determine how to share patient information.

• Are there special considerations for this specialty? For example, if you are sending a patient to a gastroenterologist for a routine screening colonoscopy, can you avoid the need for a separate medical consult prior to the actual procedure by forwarding the most recent general physical exam?

• Who is responsible for which parts of the patient's care? As mentioned earlier, the cardiologist might manage a patient's atrial fibrillation while the family physician manages the anticoagulation.

• How do you want the consultant to handle the need for another specialty opinion? This may also include a requirement to ensure that subsequent consults are also with physicians who take the patient's insurance.

• Does the consulting specialist have any “pet peeves” about how your group is approaching or sending referrals? For example, our orthopedists asked us to order weight-bearing X-rays of painful feet to avoid having to repeat the X-ray if only routine “foot films” were initially ordered.

These questions will help flesh out the service agreement itself, but there will likely be numerous other logistical obstacles you and the consultant may need to work out, which could take additional time and inconvenience. Reaching agreement on how to address any future complexities is one of the major advantages of the service agreement, and it can be aided by remembering the benefits these agreements will ultimate create for the patients.

MANAGING THE RELATIONSHIP

Good intentions and plans go only so far. Once the agreement is signed, it's important to schedule a follow-up meeting in three or four months to see how things are actually working and address any unexpected problems. Thereafter, designate a lead contact for the family medicine practice and one for the consultant practice, and agree to let each other know if things aren't working as they should.

This approach has helped keep our service agreements operational as new physicians arrive, other physicians leave, and situations change. Keeping a good line of communication is one of the most valuable parts of having the service agreement.

The process of creating service agreements may sound difficult, but it doesn't have to be, and it can flow naturally from your desire to give patients the best coordinated care. Once you get a few of these agreements completed, the process becomes easier because you have greater experience and can show prospective consultants that you have been willing to sit down and solve many of the challenges surrounding referrals. Service agreements aren't limited to large practices. We are a network of 11 primary care sites in northwestern Washington State with more than 70 family physicians, but when we started seeking these arrangements, we were much smaller. Find a group that wants to work with you, and go from there. Before long, you will have made referrals much easier for your practice, benefitted your patients, and made the medical neighborhood a more welcoming place for everyone.