March 29, 2017

How can we help primary care doctors refer to specialists appropriately?


Leah Tuzzio describes a pilot project that uses physician coaches

by Leah Tuzzio, MPH, a research associate at Kaiser Permanente Washington Health Research Institute

I am grateful I get to work in a place where I am also a patient: Kaiser Permanente. I have the opportunity to influence improving the care that my family, friends, and I receive.

I recently started seeing a new primary care doctor after my last one retired. Although I am a healthy, young woman, it was important to me to build a good, trusting relationship with my new doctor. I wanted someone who would try their best to help me stay healthy — and seek consultations from colleagues or refer me when absolutely necessary. As part of an integrated health care system, my doctor and I have a lot of resources at our fingertips, including being referred to specialty care.

Individual primary care physicians tend to vary widely in how often they refer patients to specialty care. So a little over a year ago, my research team pilot-tested specialty-referral coaching sessions at two Kaiser Permanente primary care clinics. Four primary care doctors who were specially trained coached four others in a process that one coach, Kaiser Permanente Physician Travis Abbott, MD, described as “a doctors’ duet.”

The model for coaches and physicians: Build trust and spirit to learn together, get to know your own data, talk with patients differently, and practice medicine differently. The goal: to help doctors not to make referrals unless they’re really needed.

The Permanente Journal recently published the program’s curriculum and results from interviews with the four physician teams that participated in the pilot: “Design and Implementation of a Physician Coaching Pilot to Promote Value-based Referrals to Specialty Care.” We showed that this physician mentoring program was feasible and acceptable in primary care settings. The participating doctors said that it was acceptable for physicians to talk with their peers. They also provided some ideas about what to change in the future: for instance, balancing time pressures by giving doctors time for mentoring conversations.

What’s next?

We want to further improve upon this pilot and see what, if anything, we would need to change if more doctors participated in these coaching sessions. Over the next year we are going to test adaptations to this model of one-to-one coaching, like what happens if you have one coach work with a larger group of doctors or look at referral data in advance or together. We also want to look at changes in referral rates, physician perspective, and patients’ perspective after their doctor participated in this coaching program.

My coauthors are Dr. Abbott and KPWHRI’s Evette J. Ludman, PhD; Eva Chang, PhD, MPH; Lorella Palazzo, PhD; and Edward H. Wagner, MD MPH; with Robert J. Reid, MD PhD, a KPWHRI affiliate investigator now at Trillium Health Partners. The Group Health Foundation Partnership for Innovation supported this pilot.

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