• J T Harrington, C A Dopf, and C S Chalgren.
• Rheumatology Section, Department of Medicine, University of Wisconsin (UW) Medical School, Madison, Wisconsin, USA. tim.harrington@uwmf.wisc.edu
• Jt Comm J Qual Improv. 2001 Dec 1; 27 (12): 651-63.

BackgroundImproving health care will require more effective guideline implementation and redesign of delivery processes and systems. Patient referral for specialty care is a key component of health system function that needs to be improved. Low back pain care is a widely documented example of the need for improvement. An interdisciplinary systemwide back pain program was developed using process improvement methods. Proactively managing referrals for specialty care-a departure from traditional referral processes-played a critical role in implementing the program.MethodsProgram components included guidelines for care, defined provider roles, uniform service coding, provider and patient education, pre-appointment specialty referral management, and monitoring of management processes. To evaluate program performance, system back pain visits were compared before, during, and after implementation of referral management. A case series study was performed on 581 consecutive patients with low back pain or lumbar radiculopathy referred for consultative spine care between April 1998 and March 1999.ResultsA shift of care was accomplished for acute back pain from spine orthopedists to primary physicians and for chronic back pain from spine orthopedists to medical specialists. More than 95% of initial assignments were accurate. Seventy-six percent of surveyed chronic back pain patients improved, and 90% were highly satisfied with the referral management process. This program has saved an estimated $400,000 per year in manpower cost and has reduced specialty service billings by 20%.DiscussionPre-appointment referral management offers an approach for improving guideline implementation, access to specialty services, and the effectiveness of care for complex health problems. It deserves broader study and adoption.

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