I’ve Been on Both Ends of a Referral
For several years my job was to send people onward. At a managed care medical group, I helped members get referred to services and coordinated their in-home care. Later I directed a social services program, and my team was the one receiving referrals from healthcare providers and public agencies. I know how it feels to send a referral and consider the task finished. I also know how it feels to open one and have very little idea what the sender expects.
The second experience is the one that changed how I think about handoffs.
Sending and receiving are different events
On the sending side, the work feels complete at the moment of transmission. The referral went out, the discharge summary was uploaded, or the task was assigned in the system. Each of those is a real action. None of them tells you that the receiving team knows the person exists.
AHRQ describes a handoff as the transfer of information together with authority and responsibility. In practical terms, I consider a handoff complete when someone on the receiving end has said, in whatever form, that they have the case, what they understand about it, and what they will do first. Until that happens, no one is clearly responsible for the person in between.
Receiving teams rarely need more information. They need less of it, better chosen: what is happening now, what has already been tried, what exactly is being asked and by when, and what might change the plan. A short referral that answers those questions is usually more useful than a long record that leaves the receiver to work them out.
The gaps sit between departments
Within a single team, people generally know who owns what. The failures tend to happen at the boundaries. A clinic completes a referral and never learns whether the specialist received usable records. A hospital schedules a follow-up visit without confirming the patient has a way to get there. A care manager identifies a transportation barrier and has no defined place to send it. In each of these cases the individuals did their jobs. What was missing was a decision by the organization about who is responsible for the space between two teams.
This is why I find structured tools helpful. I-PASS, which AHRQ includes in its TeamSTEPPS curriculum, covers illness severity, a patient summary, an action list, situation awareness and contingency planning, and a synthesis by the receiver. I care less about the acronym than about the habit it builds, which is that both sides know what to prepare and what to confirm before the transfer counts as done.
Two measures and a question
If I could look at only two numbers for a referral process, they would be the share of handoffs that received an explicit acknowledgment from the receiving team, and the time between sending and acceptance. Both are simple to track. They are often tracked less than whether the referral form was filled out.
I also ask one question whenever a case has gone quiet: what happens when the receiver does not respond? If the honest answer is that someone usually notices, then the process is depending on individual attentiveness, and that will eventually fail on a busy week.
The person being referred does not experience any of this as a document. They experience it as the week they spent waiting to hear from someone. Having sat on both sides, I have come to believe the most reliable handoffs are the ones where the sender and the receiver actually speak to each other, even briefly.
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About the author
Sherry Sayari, MPH, is an Operational Standards Evaluator who has led population health, community outreach, and social services programs. More on the About page.
