Referral as a key to family-centered, collaborative care

Bret Moore, DVM, PhD, DACVO, a member of the 2025 AAHA Referral Guidelines taskforce and assistant professor of ophthalmology at the University of Florida (UF), has a motto that he believes all veterinarians should live by: “If there are not two veterinary professionals who are working together, and who agree on what’s best for that patient and that client—both right then and also in the future—then we’re not doing a good enough job,” he said. “And that should apply to every case.”

In the decade or so since joining the profession, he’s become increasingly aware of how siloed vet med can be. “It’s not isolated from the standpoint of, you don’t have the resources or the people around you,” he said. “It’s more of a culture isolation where the full understanding of how those resources should and can easily be utilized are not being [utilized].”

Moore doesn’t solely focus on teaching his veterinary students at the UF College of Veterinary Medicine clinical content. In fact, he finds tremendous joy in helping them understand what to do when they don’t know what to do. “And the answer is that you collaborate with each other,” he said.

Unfortunately, that’s not the norm—and Moore knows this from experience.

A friendly specialist case study in collaborative care

One of his best friends from vet school is, in Moore’s words, “a wonderful practitioner” and the owner of a busy, 20-ish doctor practice. “He’s a fantastic vet, but I know eyes aren’t his preferred organ to treat,” Moore said. “I’m an ophthalmologist.” The two talk on the phone every two weeks or so, and, he said, “in the last six years, I think he’s asked me about four, possibly five cases.”

Moore asked if his friend would be open to Moore flying up for a visit to see what his practice does for cases involving eyes. Over the course of a single day, as he sat in the corner observing, the team brought him five cases.

“When I talked to Jeremy about this at the end of the day, we realized that none of these cases really needed an ophthalmologist,” Moore said, “but they all benefited from talking to one. And being able to sit down and talk through those cases, those clients left with better expectations.”

He acknowledges that those patients would likely have all gotten better if he hadn’t been there to weigh in, but believes that his expertise may have made the course of treatment faster and/or more cost-effective.

“And so our realization is that—and I’ve experienced this plenty with the referral calls that I get—it seems like when things are dire, the worst of the worst, then we definitely need to call [a specialist],” he said. “But all the times that we’re not 100% sure on something? There could be a lot to be gained from that as well. That’s where I’m taking a stance on collaborative care: That it should be done on a regular basis, not on a once a month dire, terrible case basis. I think our profession and everybody involved would benefit from that.”

Practical benefits for the practice

One of Moore’s favorite things about collaborating in this way is how it helps veterinarians and their teams improve their skills—and their confidence.

“I’ve taken cases from the same doctor over the period of a year or so, where it’s the same condition, but just a slightly different variant,” he said. “You realize at a certain point the confidence that’s being gained in that, and then, all of a sudden you don’t hear from them about that specific thing anymore. And you know why? It’s because they got their own little mini, personal CE.”

There’s also a connection between collaborative care and increased client retention, which Moore noted was quantified in a Collaborative Care Coalition study.

The study looked at where the point of frustration was for clients going to a general practice for dermatology problems that were not being resolved. “It’s usually about the third visit, around $1000 spent,” he said. “And then they followed up with some data that asked about what would help alleviate that level of frustration, and what was the result of that level of frustration?”

The result, he said, was that close to 60% of those clients said they would not go back to that general practice veterinarian for anything but basic, routine care. But, here’s where it gets juicy: “Almost 90% of those people who would not go back said that their concerns would have been abolished if they would have known there was another option to increase the standard of care.” In other words, if they’d known their primary care veterinarian could have employed a collaborative care approach to connect with a specialist, that would be a game changer.

Another study, which Moore conducted but has not yet published, is based on the cases that were referred, after hours and without any phone call, to the ophthalmology department at the UF Veterinary Hospital.

“So, [the clients] show up here after hours, and our resident—or me—drives in in the middle of the night to look at this case,” he said. What he found was that over 65% of those cases were at the level of the fourth year graduating curriculum.

It’s not that he thinks every veterinarian should automatically know how to treat that—he even tells his students that he doesn’t expect them to remember every detail. What he hopes they do remember, though, is where to find those answers.

And these cases? “They would have been manageable by a simple 5-10 minute phone conversation,” he said. But instead, he said, people are driving, in the middle of the night, several hours to seek help. They’re getting a hotel, and they’re spending $700 to be seen as an emergency.

“It could’ve been a quick, simple thing,” he said.

Why don’t we all make the call?

So, if collaborative care benefits the patient, the client, and the veterinary team, why isn’t it the norm? Moore has identified a couple of the most common reasons.

First, many veterinarians are worried about appearing incompetent in front of their clients when they don’t have the answer. “My argument is that it actually shows ultimate caring, that you would go out and take the time to call a specialist to bring the best care for their pet,” Moore said.

Secondly? It’s just not how it’s done.

Moore recalled a second trip to his friend’s practice, where he didn’t go specifically to help, but just to observe.

“I watched one of his veterinarians spend 45 minutes walking around the clinic, asking three of the other associates what they thought about a dermatology case,” he said. “And in the end, she still didn’t have a clear-cut answer on what to do, and, I mean, she could have consulted with a dermatologist in less than a quarter of the time—and had your answer.”

It also comes down to time. Yes, a “quick” consultation might only take 10 minutes, but when you’ve only got 15 minutes scheduled for an appointment, that’s still hard to squeeze in. Moore understands how difficult that is and believes it will take a huge profession shift to create schedules that allow for this type of collaborative care—but ultimately, it’s better for the patients, and it’s worth the effort.

But it’s not only the referring veterinarian’s time to consider; they also may be worried about taking up too much of a specialist’s time. “One of the other reasons I’ve heard that a lot of veterinarians don’t want to regularly seek advice … is because they feel they don’t want to be a bother,” Moore said. “Can you imagine calling three times a day to the same internist, times 300 vets that are in the area? It’s just not tenable.”

(And, as someone who gives his number to his students and still fields calls from those he taught 10 years ago, he does have some experience with this.)

Making a call to a specialist you’ve built a relationship with now and again, for cases with a definite need for referral, is one thing, he said. “But when you have instances like, ‘I’m 90% sure, but not quite there,’ or the question of ‘I don’t think this needs to go now, but do you recommend that maybe in the next week this should be seen—and what can I do until then?’ That’s a great question for a collaboration,” he said.

Putting it into practice

There are a lot of resources for that, he said, and the paid aspect of some of those resources takes away that “I don’t want to be a bother or take up your time” concern. “There are some resources that are very cost-effective in terms of a paid aspect that allow the veterinarian to upcharge within what’s still a really good rate for those clients,” he said. And that allows the veterinarian to still benefit financially from the transaction, which, Moore said, is critical because they are taking time out of their day to, essentially, run a diagnostic test through that consultation.

“[The general practitioner] should be compensated just the same as the consultant,” he said, “and what’s brilliant about it is that there’s no need for adding additional staff. You don’t need to purchase any equipment.” When done strategically and with the appropriate fees attached, he said, it’s an easy revenue generator for the doctor and practice, and it’s going to help them do their best for their clients and patients.

He’s found that clients are extremely receptive to this—but, as you might imagine, the way you frame it makes a difference.

“Let’s say you walk into the exam room and say, ‘This is my plan. I think it’s a good idea; however, it might be nice to get a dermatologist on the line, just in case there’s something new or on the cutting edge that could help reduce the cost or duration of your treatment of this condition. Would you be OK if we could do that for a nominal fee?’” Moore said. “And when you’re talking about a third of the price of [an in-person] referral, minus the travel time, and the wait, and the day off, there aren’t many clients who would say no to that.”

Reaping the benefits of the Referral Guidelines

“I think the guidelines are an excellent starting place for the process on the referral,” Moore said. “A couple important things to remember is that the process can be edited, so, if you’re in a local relationship with your specialist and you want to run things a little bit differently, that’s wonderful! But I think having that conversation about how to edit that is the best way to go about it.”

But the most important point, he said, is that communication with the client must happen. “Regardless of whether a referral is indicated, desired, or can even happen at all due to financial or distance concerns, we need to be having regular communication with one another to do the best for our patients and clients.”

Photo credit: AAHA

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