Section 5: Responsibilities After Referral
Top 3 Takeaways
- Re-establish the PCT relationship with the client by reviewing the referral records and discharge notes and initiating a follow-up discussion.
- Establish a clear plan for continued patient and client care, including delegation of responsibilities, expectations for continued collaboration between PCT and SCT, and client contact.
- Practices may assign a designated team member or referral coordinator to the case to ensure timely ongoing follow-up.
Joint Responsibilities After Referral
During this time, direct care for the specific health concern for which the patient was referred is transferred from the SCT back to the PCT. Communication often falters after a referral, but continued interaction between PCTs and SCTs is key to long-term patient care and client satisfaction. Both parties must maintain effective communication as the patient transitions back to the PCT for follow-up care.
Communication is best continued via the mechanism used during the referral for consistency, whether through a recommended web-based portal or by phone, email, text, fax, or social platform. To ensure ongoing follow-up occurs promptly, practices may assign a designated team member or referral coordinator to the case. At all times, maintain a clear understanding and consensus between the SCT and PCT of the short-term and long-term goals of the patient’s continued care plan. Sharing information and records that include a running history, findings, assessment, diagnostics, plan, and updates with the client proves both useful and necessary to achieve this goal.
In some cases, long-term follow-up care may fall to the SCT, either based on client preference or owing to the complexity of the case. This can be decided on a case-by-case basis with discussion between the client, SCT, and PCT to determine what is best for the patient and family.
SCT Responsibilities After Referral
The SCT communicates to the PCT that care has been completed for the specific health concern for which the patient was referred. Upon the decision to transfer direct care back to the PCT, the SCT provides:
- A clear account of what occurred during the referral (Figure 5.1)
- A discharge report with the following minimum information:
- Diagnosis (tentative or finalized)
- Prognosis
- Current patient status
- Medications prescribed
- Special diet prescribed
- Treatments to be performed at home or at the PCT facility
- Follow-up care needs, including the recommended timeframe for rechecks and which team is responsible for follow-up diagnostics and treatments
- Any pending tests, the expected timeline for completion, and who will communicate those results with the client
- The best method(s) for continued collaboration between the PCT and the SCT (e.g., when general collaborative communication is appropriate versus the request for an additional consultation).
Generic follow-up recommendations, such as suggesting laboratory work, should be avoided with the PCT. Instead, follow-up suggestions should be as specific as possible, such as recommending a follow-up appointment with the PCT in 2 wk for a complete blood count to monitor the correction of anemia, or for the removal of sutures or surgical staples. For pending tests, the SCT notifies both the client and PCT of the results and any changes indicated to the follow-up plan.
FIGURE 5.1: Post-referral form example
PCT Responsibilities After Referral
At the end of the referral period, the PCT re-establishes itself as the directing care team. This means supporting the treatment plan recommended by the SCT. To resume care, the PCT reviews the patient’s history from the SCT and confirms the required documentation is included. If necessary, the PCT contacts the SCT to request clarification.
The two teams should reach an agreement regarding compensation for future consultations, as the SCT should not be expected to provide indefinite help managing the case without compensation for their time and expertise. If the PCT would prefer that the SCT manage the ongoing problem or condition, it is appropriate to let the SCT know.
The PCT also re-establishes itself as the directing team for communication with the client. The PCT can connect with the client by asking open-ended questions regarding the patient’s mentation and behavior since their most recent visit, medication administration, and any concerns they have related to the treatment plan. Such essential discussions facilitate patient care and ensure clients follow through with treatment and follow-up plans. Listening to the client’s feedback regarding the care experience under the SCT is an essential aspect of the referral process. The PCT can share these client assessments with the SCT as relevant, including considerations regarding family-centric decisions, positive feedback, constructive feedback, and any concerns with the plan moving forward.
The PCT’s communication with the client includes details about future examinations, diagnostic results, and modifications to the treatment plan. The PCT also takes responsibility for scheduling follow-up examinations, laboratory work, or other diagnostics as necessary to successfully continue the patient’s care as recommended by the SCT’s treatment plan. Some patients require multiple visits or direct follow-up with the SCT, so clearly delineate these details in the treatment plan. A designated PCT member can communicate relevant or time-sensitive updates to the client. Schedule team members accordingly to allow enough time for these discussions with the client via phone, email, or virtual platform.
The 2025 AAHA Referral Guidelines are generously supported by CareCredit.
