Which of the following should a referring provider verify when giving referrals?

If you need to refer your patient to one of our specialty services, we will coordinate your referral request with the appropriate specialty service, and provide you with information as to the status and outcome of your referral request.

REQUEST AN URGENT REFERRAL

Call our Physician Referral Center at 800-4-UCDAVIS (800-482-3284), option #3. 

Please note that urgent self referrals are not accepted. Patients must obtain urgent referral from primary care provider.

REQUEST A NON-URGENT REFERRAL

To initiate a referral on behalf of your patient, please click the button below to submit an electronic referral form.

Electronic Referral Form

Please be advised that incomplete information or need for clarification may delay referral processing.

Clinics listed below should be contacted directly to initiate a referral:

Checklist for non-urgent referrals

Prior to submitting a referral, please complete the following:

• Obtain insurance plan authorization
• Confirm patient name and name on insurance card(s)
• Obtain copy of most up-to-date insurance card(s)

IMPORTANT: Please submit the following with your referral request

• Completed UC Davis referral intake form (included in the Referral Request Kit)
• Recent/relevant clinical notes/test results (health history, physical, MRI/Ct/X-ray results, etc.)
• Proof of insurance
• Authorization information with CPT code details and approved visits

Total Time: 55 minutes

Module objectives: Participants will be given a model for delivering HIV test results, and a chance to practice in simulation. Strategies for successfully referring patients into HIV testing and care as well as other services will be addressed.

Preparation: Flipchart; Delivering HIV Test Results (Slide 15) and Steps in Effective Referral (Slides 16-17).

DELIVERING TEST RESULTS

Time: 15 minutes

Materials: Flipchart, Slide 14

The first task for health care workers offering HIV results is to think about the emotional responses patients may have to HIV test results.

Ask participants what emotions they have seen in patients whose test result is negative. Listen and confirm responses, adding any from your own clinical practice. Expect answers like:

• Relief (at not having HIV)

• Excitement (elation at good news)

• Confusion (may have perceived themselves as positive; may have positive current or former partners)

• Optimism (may feel like a new opportunity)

Next invite the group to consider the emotional reactions for patients whose test result is positive. Again, confirm all responses, and record them on flipchart. Highlight these possible emotional responses to bad news:

• Confusion

• Anger

• Denial

• Sadness

• Loss

• Bargaining

• Uncertainty

• Fear of death/pain/prolonged illness

• Shame/embarrassment

• Fear of rejection

• Disbelief

Ask participants to view the list of possible emotions and identify the ones they expect they would have if they tested HIV positive. Ask for volunteers to respond. If they need another prompt, ask “Which of these would be your reaction to hearing someone tell you that your test was HIV positive?” Invite as many participants to share their reactions as desire to do so. Thank each one without additional comment.

Once this is finished, review newsprint from earlier in the day on which participants discussed the qualities they would hope for in a health care provider labeled “Helpful traits”. Ask participants which of these traits would be important to them as they consider their emotional reaction to HIV test results. Confirm all responses.

Explain that sensitivity to patient emotions, coupled with accurate medical information and helpful referrals, are the cornerstones of effective delivery of HIV test results.

Reveal Slide 14, and discuss steps for delivering HIV test results:

• Verify patient identity: Ensure that the person to whom you are giving the result is the same person who submitted for the test. Re-check name, code, or identifying number, or whichever was presented for testing.

• Assess patient readiness to receive results: Note that most patients are completely ready to hear the news of their results, and this should not drag out the waiting time. Rather, a short check in [i.e. ‘Are you ready for your results?’] allows the patient to control this process and offers an opportunity for any additional questions or information.

• Deliver and interpret HIV test result: Promptly deliver the result, offering explanation of the test's meaning. One effective strategy can be, “The test result is positive/negative that suggests you DO/DO NOT have HIV in your blood.” This informs patient of the results, but also doesn't rely exclusively on use of terms reactive/non-reactive or even the terms positive and negative which may be confusing.

• Allow for emotional reaction: It can always be helpful to allow some time for silence after giving news, particularly a positive result. Offering an empathic comment [e.g. “This is really hard news to hear.”] gives your patients a chance to talk about their emotions, perhaps to have them validated. If you have time and feel comfortable, use of open-ended questions about their feelings is an excellent method for supporting patients at this point.

• Provide follow-up teaching/medical information as appropriate: It may be important to remind patients about recent exposures and the need to be re-tested if they receive a negative result. Patients who test positive should be counselled about the need for medical follow up, availability of additional support services, and the need to notify sexual partners so they can also obtain testing.

• Offer referrals and follow-up options: Knowing about community resources to address needs, especially for persons who test positive, are critical for delivery of high quality HIV testing services. Reminding patients of additional services, including HIV care treatment and prevention (condoms, PMTCT services etc) at your health facility is important.

Note

Numerous studies on patients with current STI and recent HIV exposure suggest that these patients may be especially infectious because of high levels of virus following exposure. Particular emphasis on detection of acute HIV infection and education on need for re-testing is especially important in light of these findings.

RESULTS-GIVING PRACTICUM

Time: 45 minutes

Materials (Optional ): PITC video - scene 4, 6, 7

State that the course will now offer a chance for participants to practice delivering an HIV test result.

Ask participants to partner with one person in the group with whom they have not worked during the training. Once groups have formed, tell the person whose birthday is closest to January 1 that they will play patient in this simulation. Ask them if they are willing to be patients who have been tested in the health center. If so, ask them to step out of the room while you instruct the health care workers.

Participants left will be health care providers. Advise them that they get to choose which results to practice. State that the suggestions of the previous section should guide this intervention. They should imagine the patient had been tested two weeks ago, and they have returned for their test results. The patient will be led back in just a moment to hear test results. Again, remind provider they should determine if they would like to give a positive or negative result in this practice session.

Bring patients back into the training room, and advise them that their test results have been read and their provider is prepared to discuss them. Instruct them that some sessions may take longer, so if they finish before 10 minutes, they should quietly discuss the session with their provider. Ask providers to begin result-giving simulation. Monitor participants' work, and after 8-10 minutes end the simulation.

Ask patients to debrief with their provider by focusing on all the ‘successes’ they observe. Instruct them to focus on the specific details of what providers did well. Invite participants to discuss among themselves what went well initially, and advise them the group will have a discussion after they have concluded.

Allow five minutes for partners to debrief, and then ask the group what went well. Ask some participants what felt good to them when they were given results. Invite counsellors to discuss their reactions to this process, and what aspects they felt worked effectively.

Transition to the next activity by stressing that one of the most difficult things health care workers face in doing HIV testing is delivering a positive result. Suggest you would like to demonstrate a result-giving session which applies the steps outlined earlier to the task of giving positive results.

State that you would now like to demonstrate a counselling session attempting to accomplish the steps outlined above.

NOTE

You should prepare a patient scenario in advance. If possible, you should rely on having your co-trainer in the role of a patient.

For an IMAI training, prepare an Expert Patient Trainer for this role.

Invite your patient to sit down. Begin demonstrating HIV result-giving, using the steps outlined as a guide. You should demonstrate giving a positive test result. Incorporate into your case some dynamics that relate to issues which have been discussed in the training.

Conduct a demonstration for 10-12 minutes. At a logical stopping point, call time.

Invite your patient to de-brief, focusing first on what they felt good about. Next, ask if there was anything they would have liked their counsellor to provide that they didn't. Confirm all responses.

Invite other participants to comment, addressing their positive comments first, and then invite their suggestions for improving the interaction. As before, listen and confirm all responses.

Once discussion has ended, transition to the next activity by asking providers if they felt the patient they were seeing could benefit from additional community services or medical care. Next, ask how often real patients will need support or medical services from the HIV testing center. Acknowledge this common occurrence. Explain that the task is so important, there will be some time taken to focus on steps for making effective referrals.

STEPS IN EFFECTIVE REFERRAL

Time: 20 minutes

Materials: Steps in Effective Referral (Slides 15-16)

Begin the module by emphasizing that one of the most important components of post-test support in the provider-initiated testing session is the process of making referrals. Emphasize this is especially important for persons who test positive.

Reveal Slide 15 (continue with Slide 16) and offer some suggestions for effective referral, emphasizing that the goal is to maximize the likelihood that a patient follows through with the referral.

Referral letter. A referral letter establishes authority and assists the client to act on their own behalf. It should be noted that a referral is not a way to pass a problem along, but has a meaningful purpose for promoting a client's well-being.

Observe confidentiality. Confidentiality must be observed. Patients should know what information about them is included in the referral. The referral letter which you are giving to the patient should not contain any information that you would not want them to know or that might be harmful to them if it is lost or misplaced. Agency guidelines should determine the nature and content of information to be included on referral forms.

• Maintain and update directory. Ensure that a directory of post-test support services is developed, maintained, and updated as necessary. This resource facilitates easy access to a listing of multiple services and programmes for persons who need a variety of support services. Know the resources that are available in your community and use them.

• Refer to known and trusted resources. The most effective referrals link clients with providers with whom you have had experience and who can deliver quality services.

• Offer referral as one option. In a client-centred approach, the referral is offered as one possible resource. It is contradictory in a humanistic approach to mandate that clients seek a particular service: this is both disempowering and holds the possibility of clients reacting to our directives by rejecting them.

• Assess client's reaction to referral. Note that clients may have a history with agencies and providers, and some referrals may have negative associations in a client's minds. While it is the client's right to refuse a referral, it is your responsibility to offer.

• Orient clients to agency services in your referrals. Let clients know what to bring, how to get to the agency, and what to expect – this will minimize the chance that clients ‘fall through the cracks’ of the referral process or the agency service plan.

• Assess level of support for active referral. Client empowerment means giving some clients little direction and encouraging them to follow through, while other clients may need to have appointments made or an assistance plan developed. Managing the balance of providing too much support or not enough support is a critical clinical determination.

• Follow-up with client and referral source as appropriate. Determine mechanism to find out from client and/or provider if client did follow through and how successful the interaction was.

• Receiving referrals. This is an equally important part of the referral process. How you receive and treat a referred client will determine the success or failure of the intervention. It is important to acknowledge receipt, preferably through a written response. Where possible you may also wish to make a quick phone call to the referring agency just to inform that the referral has been used. All agencies should establish follow-up and evaluation procedures.

• Disclosure and partner notification. Your role is to assist clients who are HIV positive to understand the importance of disclosing to their partner if they are able to do so and to encourage that their present and former sex partners be tested if this has not already been done. It is important that providers assist clients to develop a plan for disclosure. It may also be beneficial for clients who test HIV negative to discuss their result with their sexual partner and for their partner to undergo HIV testing. Emphasize that most HIV transmission occurs in stable relationships and discordant results (one partner testing negative and the other testing negative) are common.

  It is suggested providers allow clients to discuss their fears and ask questions about any critical challenges that they may face, such as violence; this can direct where and to whom you refer the client.

  Explore possible immediate sources of personal support such as friends or family. Referral to an identified professional, support group or agency can be useful for providing support and coaching in disclosure and partner notification.

Invite any final recommendations and suggestions for making referrals. Listen and confirm any responses.

Finally, acknowledge that the primary care provider may not have time to perform all the necessary functions associated with making referrals. Ideally, the primary care provider would be the person who explains and emphasizes the need for and availability of treatment and care. In any event, the chief concern for the interdisciplinary team must be an assessment of appropriate referrals for clients receiving HIV test results and employing clinical skills to encourage client follow-through on referrals made.

Transition to the workshop closure by explaining that the content for the workshop has been completed, and the final steps in the workshop will begin.

What are the steps of referral system?

Who is ultimately responsible for making a referral?

How does a referral work?

What are the reason for referral?