Helping You Apply the College’s Continuity of Care Expectations
We answer your questions
In September, our goal of ensuring patient safety was furthered with Council’s approval of four inter-related continuity of care policies. As with all policies, our aim was not to set out specific instructions for every practice type or clinical encounter. Rather we set out broad expectations that still enable and require physicians to exercise their judgment in determining how to apply those expectations to their practice and to deploy different practice measures to align with the policy expectations.
However, in the weeks and months following Council’s approval of these policies, we have received some questions from doctors asking for specific direction or clarification about the College’s expectations.
Given the significance of these policies, and our commitment to support you as you provide care to your patients, we’re following up here with some clarification and answers to specific questions we’ve been receiving. In particular, we have been asked to provide more guidance about the referral and consultation expectations set out in the Transitions in Care policy. These expectations were developed to help minimize information breakdowns and keep patients safe.
Q: The consultation draft gave the referring physician the responsibility for communicating appointment information directly to the patient. Why was it changed to now give the consultant the responsibility?
A: That is correct. The draft policy included an expectation that the referring physician would communicate this information on behalf of the consultant.
But it became evident through all our consultation activities that having the referring physician communicate appointment information with the patient was not the right position.
It didn’t align with other medical regulatory bodies across the country, and it didn’t align with the Schedule of Benefits — which includes making arrangements for an appointment as a constituent element of the care being provided by the consultant physician. It also increased the risk of breakdown in communication as it added one more layer of communication to multiple layers of phone tag.
In response to these factors, as well as the feedback we heard from physicians and key organizational stakeholders, our Council decided to change the final position and require the consultant to communicate appointment information (i.e., wait time or appointment date) directly to the patient.
Q: But this requirement places an added burden on staff in consultants’ office.
A: As noted above, consultants are already being paid for this administrative task. The Schedule of Benefits anchors the responsibility of making arrangements for an appointment with the physician who is billing for the service, in this case, the consultant physician.
Q: How should I, as a consultant, communicate appointment information with the patient?
A: The College is not prescriptive about how consultant physicians should communicate appointment information with the patient, as we recognize that different practices may adopt different approaches that work best for them. Referring providers can play a role in this transition, by working with consultant physicians to develop and carry out new processes to support it. This could include collecting and sharing additional contacts for the patient (e.g., email, mobile phone), along with patient consent, as part of the referral request.
Regardless of the mode of communication (i.e., phone, letter mail, email etc.), physicians always have an obligation to maintain patient confidentiality while recognizing that not all information is equally sensitive and that it is essential to the provision of care that appointment information be communicated quickly and effectively. In particular, it would generally be appropriate to leave a voicemail to share basic appointment information so long as additional, more sensitive information is not shared.
Q: Can I decline any referral where the referring provider is not willing to communicate the information on my behalf or where I can’t communicate with the patient in my preferred form of communication?
A: No. The policy is clear that the expectation is on the consultant, unless the referring provider has indicated that they intend to do so. Declining a referral because you would need to communicate the appointment information would not be consistent with the Accepting New Patients policy. Referrals can only be refused if you are no longer accepting new patients or if the referral is for a clinical reason outside your scope of practice. Of course, the policy also permits you to prioritize patient access based on need.
Q: How much of an effort do I need to make and what if I run into difficulties?
A: Just like any other administrative task — rescheduling an appointment, communicating important test results, or arranging appropriate follow-up – consultants must make reasonable efforts to contact patients about their appointment. If you are having difficulty reaching the patient, it will be important to document your attempts and communicate with the referring provider so they are aware of the challenges and can work with you to best support the patient.
Q: Can I ask the referring provider for assistance in communicating the appointment information?
A: There is nothing in the policy that prevents physicians from working collaboratively to find the best way to share appointment information with the patient. Ultimately the responsibility is on the consultant physician however some referring physicians may have a preference for sharing this information, especially during stressful or difficult times for their patients. The policy also doesn’t prevent institutions from developing their own processes for managing this task across departments or divisions in a way that ensures the information is being communicated appropriately and directly.
Q: Where do diagnostic facilities or radiology units fit in the policies in terms of coordinating or communicating appointment information to patients?
A: Diagnostic facilities and radiology departments within hospitals have a unique place in the system, serving a role that is similar to laboratories in that radiology procedures are generally accessed through a requisition rather than a traditional referral. As such, the expectations for communicating appointment information in the Transitions in Care policy are not intended to mandate how these procedures are booked.
Q: Do emergency department physicians fit within the Walk-in Clinics policy? What are their responsibilities when making a referral?
A: Emergency department physicians are specifically excluded from the Walk-in Clinics policy. That policy sets expectations only for those physicians practising in a walk-in clinic, as defined in the policy and explicitly excludes emergency departments within hospitals. The intention was not to address the broader issue of episodic care through these policies.
With respect to making and managing referrals, emergency department physicians have a clinical responsibility to make referrals that are indicated as needed. But due to the unique role they play in the system, they may not be best positioned to manage the referral on an ongoing basis once the patient has left the hospital. The close working relationship emergency departments have with family physicians in their community supports coordinating a hand-off of responsibility for the referral, indicating to the consultant physician that the emergency department physician is effectively making the referral on the family physician’s behalf.
The intention of the policies is to ensure that information sharing is occurring and that the patient’s care is actively being managed. The policies do not prevent handing-off responsibility for the referral between providers in a coordinated way. There are many ways that this hand-off can be achieved, and as long as it’s clear and coordinated, the practice would be consistent with the intention and requirements of the policy.