“The Act of Making a Referral is Not Enough”

Building a Referral Process that Works 

pediatrician and healthy babyNearly 25 percent of young children in the U.S. are at risk for developmental delays. If not identified, these delays can hinder their ability to perform well in school, develop meaningful relationships, and reach their full potential. Universal developmental screenings can proactively identify children who are at risk of having or developing a delay so they’re referred for further assessment and interventions that will positively impact their lifelong health. Because success in life depends on healthy development.

An effective screening process relies on successful referrals—if there is no follow-up with the referred child, families can never access the supports the child may need, and that child may ultimately fall through the cracks despite the screening and referral being initiated. That’s why referral to needed supports is one of the primary drivers for Pediatrics Supporting Parents, a NICHQ-led national quality improvement initiative with the global aim that all children start kindergarten healthy and ready to learn. Screenings and successful referrals are critical ingredients for promoting kindergarten readiness throughout our nation.

“When you’re busy in pediatrics, it’s easy to think, 'ok, I’ve made the referral and now someone else will take it from here,” says Dipesh Navsaria, MPH, MSLIS, MD, associate professor of pediatrics at the University of Wisconsin School of Medicine and Public Health and founding medical director of Reach Out and Read Wisconsin. “But the act of making a referral alone is not enough. We have to follow through and ensure families understand the need and can follow through on the advice given; it comes down to improving care coordination as a type of fail-safe to make sure the referral is successful.”

Given that more than 80 percent of children with a developmental delay don’t receive needed intervention services before 3 years of age, improving the pediatric referral process is a critical strategy for giving more children the chance to start school ready to succeed. At a Pediatrics Supporting Parents learning session, Navsaria—who is a faculty expert on the initiative—led a workshop on building a referral process that works. Here are five takeaways.

1. Build trust with families

A lack of trust can get in the way of the referral process, says Navsaria. Families need to trust the provider’s recommendations and feel informed and motivated to act on the advice given, all of which depends on trusting, positive parent-clinician relationships. Below are three ideas:  

  • Talk to your staff members about the need for kindness, courtesy, and compassion at all times so that families feel comfortable and cared for throughout their visit. Remember, says Navsaria, your clinic is only as courteous as your least courteous staff member.
  • Respect family opinions about their child. If a family is anxious about their child’s development even after you’ve reassured them, this is reason enough to refer them for further evaluation. If nothing is wrong, they’ll come back comfortable about their child and more confident in your relationship with them.
  • Personalize the referral process. After a provider identifies a need for referral (either for further assessment or to supportive services), families are usually directed to another staff member to discuss how to set up the referral appointment. If possible, try to have a designated person who shepherds families through the referral process, says Navsaria—someone who will set up the appointment, get whatever records are needed over to the referral agency, and will call the family to confirm their appointments. When families know there is one person guiding them, it builds trust and makes the process easier.

2. Check if the family is ready, willing and able

Making a referral doesn’t guarantee that the family will agree with your recommendation; they may not see an issue with what you’re seeing, or they may have heard conflicting advice from friends, extended family, and on advice websites and forums they frequent. And without the family’s buy-in, the likelihood they’ll follow-up for referral is small. Take the time to talk through your recommendation with families, explaining what the screening shows and why addressing a developmental delay early can have life-long consequences. Before they leave, make sure to check for their understanding on why they are being referred, so you can address any misinformation.

Extenuating circumstances, such as housing instability or food insecurity, may also understandably put a referral appointment low on a family’s list of priorities. That’s why Navsaria recommends assessing priorities to help judge if there is something competing for their time, resources, and attention.  If parents list other priorities, pediatricians can explain the urgency of the referral while engaging in a larger conversation about the social determinants affecting the family’s health—and ideally, how to address those as well.

“Try saying, ‘I understand your priorities, but I worry if we wait too long to address speech we will lose an important opportunity for change. Let’s work together on the other problems you’ve identified while also making time for this appointment,’” explains Navsaria. “This tells families we understand their priorities and want to support them, and it gives them a new piece of information: if you wait, this will ultimately be harder for you and your child.”

3. Make sure families can get to the referral

If families can’t get to the referral appointment, they’ll miss it, which is why it’s important to consider location, time and cost constraints. Try to refer them to an appointment in their neighborhood, near their daycare, or close to where they work or where one of their other children goes to school. Talk with families about the cost of the service or program and what their insurance can cover. And be sure to check availability; if there is a long wait time, it’s more likely families will end up missing the appointment.

Since it is not always possible to refer to convenient locations, consider what other innovative solutions your practice could implement. For example, talk to your referral agency or a home visiting service and see if someone can physically be in your clinic once a week, even if it is just for a half a day. This not only makes things easier for families, but it also helps alleviate any potential concerns about trusting their child with a new person they’ve never met. The referral is now in a place they know, and their pediatric provider is right down the hall—and if you know that person’s name and can tell that to the family, it indicates your bond and trust with that person!

4. Establish a strong relationship with the referral agency

It’s important to develop a relationship with your referral agency, says Navsaria. “When we move beyond mere communication to collaboration, we not only smooth this process, but it becomes possible to start moving the needle on bigger issues and maybe even achieve collective impact.”

A first step to building this relationship is developing a plan for communication between you and the agency. Talk to them about what information they need when you make the referral, and what you need from them after each referral (e.g., whether the child made it the referral or whether the child was referred to a specialist). And discuss the format of those communications; a succinct paragraph is often more effective than a lengthy report, and easier for both of you.

Remember, says Navsaria, a poorly functioning referral location can reflect poorly on your practice and erode trust between you and the family. A little work to evaluate where you are referring families to can pay off.

5. Develop a measurement strategy

Measurement is critical for tracking the success of your referrals and monitoring changes in your process for improvement. Below is a short checklist to help inform your measurement strategy.

What to Measure Who to Ask for the Information
Was the referral completed? Referral agency
Was there communication back from the referral agency? Pediatric practice staff
Does the family understand what happened at the referral and purpose of it? Family (through brief survey at next well-child visit)
Was good care delivered?

Family (through brief survey at next well-child visit) and pediatric practice staff.

Remember, it’s possible for a family to feel things went well, but perhaps important issues were never addressed (or the other way around)