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Referral Letters

Author: Morgan Liotta

The right letter

Ensuring referral letters are appropriately detailed is an essential step in providing the best care for older people in general practice.

As Australia’s population continues to age, GPs are seeing an increasing number of older patients. The likelihood of these patients having more than one chronic condition that requires referral to a specialist is relatively high, and it is important that practitioners ensure continuity of care between each specialty by providing adequate information in their referral letters.

Managing multimorbidity, medication and mental health issues in older people can be complex, and communication across all healthcare providers – from the initial consultation with the GP, to specialists, hospital care and aged care facilities – is a key element to better patient outcomes.

Dr Chris Bollen, GP, Director of BMP Healthcare Management Consulting, and facilitator of the Connecting Health and Aged Care Services Effectively (CHASE) project, is passionate about caring for older people. He believes that, as the first point of contact for their healthcare, GPs play an essential role in guiding older people through what can be a vulnerable stage of their lives.

‘We have an informed responsibility as their [the older patient’s] primary healthcare provider and care coordinator to actually make sure that all that information is up-to-date and transferred to the next person on the referral chart,’ he told Good Practice.

According to Dr Bollen, the first step in writing quality referral letters for older patients is a comprehensive health assessment by the GP, including a social history of the patient’s living situation to convey accurate and up-to-date information, which assists in providing a high-quality referral letter to pass on to each provider involved in their care.

Dr Bollen stresses the importance of all healthcare providers involved in the care of an older patient being aware of their potential conditions, including existing chronic diseases and cognitive impairment, as well as any accompanying mental health issues.

‘Referral letters need to inform the next provider of all of [the older patient’s] health issues, not just the one they are being sent along for,’ he said. ‘The right information from the GP to the next provider needs to cover the physical limitations, as well as any cognitive limitations, that older people have.

‘How to improve communication comes back to the organisation involved in delivering the care. If we take patient-centred care into consideration, older people are great users of healthcare and aged care services, but their journey can be poorly understood by those who provide it if they don’t put themselves in the shoes of that older person.’

Prof Dimity Pond, GP and Professor at the University of Newcastle School of Medicine and Public Health, has a special interest in older patients, particularly those experiencing cognitive impairment and depression. She has found that it can be difficult for older patients to remember all of their conditions and medications, especially if they have cognitive limitations, and answers to the same questions asked by various healthcare providers won’t always be consistent.

This potential inconsistency increases older patients’ vulnerability to having important healthcare information overlooked, as there are gaps left to fill in order to better manage their health.

‘They can’t necessarily fill the specialist in with details that aren’t there in the letter, and they may not be able to ask the questions that are needed, either,’ Prof Pond told Good Practice.

Prof Pond believes referral letters for older patients require special consideration to ensure the correct information reaches the specialist.

‘Most [older people] have a number of different chronic illnesses that can impact on even a simple thing, like an ophthalmology review; if they’ve got hypertension, that can show up in the eyes; if they’ve got diabetes, that can show up in the eyes,’ she said. ‘Specialists should know about these things and how well they’re managed.’


Filling the gaps

Dr Bollen views hospital admissions and presentations to emergency departments, which are relatively common among older people, as an example of their vulnerability which should be treated as a sentinel event; however, he believes many of these instances can be avoided if the correct steps are taken during the initial general practice consultation.

One of those steps is for practitioners to be aware of older patients’ polypharmacy, namely their medications and the dosages in which they are taking them.

‘It’s pretty critical to get that right in the handover to the next provider and know what the correct medication is,’ Dr Bollen said. ‘We know that communication errors in medicine are one of the highest causes of hospital admissions.’

Patients who experience some memory loss, which naturally impacts on their ability to give and receive information, may not always remember what medication they are taking, when to take it, or feel confused and disrupted if their medication changes. It is thus imperative that all healthcare providers are aware of the patient’s cognitive impairment in order to reduce the risk of potential harm and hospital admission.

‘If we don’t take the time to get it right in our interactions among healthcare professionals, whether it’s referrals for private specialists or emergency departments, then we are simply going to be adding to the problem, rather than managing the problem better,’ Dr Bollen said.

When it comes to hospital admissions, Prof Pond also believes the details within a referral letter are paramount to ensuring the safety and effective care of the patient. In particular, she recommends presenting clear information for surgeons about any diagnosis of cognitive impairment.

‘I have taken to writing [pertinent information] somewhere very visible, because people with cognitive impairment are more likely to experience delirium post-operatively and climb out of the bed, start seeing things and wandering around the hospital,’ she said.

‘That kind of thing is much more common if you’ve already got an impaired brain and then have an anaesthetic. So it results in a longer length of stay.’

In addition to the surgeon being aware, Prof Pond feels other actions can be taken to help avoid this type of situation.

‘Like putting the person closer to their nursing station so nurses can keep an eye on them,’ she said. ‘But there’s no chance of that happening if you don’t put the information in the referral letter.’


Geriatric medicine

Dr Bollen believes GPs could benefit from greater levels of training in geriatric medicine being implemented earlier in their studies, as it covers a broad range of illnesses and conditions that can present in older people, rather than just the separate study of a single disease.

‘We’ve been trained very specifically in single-disease and single-organ care, but geriatric medicine is all about the holistic care,’ he said. ‘And, as we look at who is actually in our hospitals, the 65-plus age group is a dominant group.

‘We’ve got junior doctors and junior nurses being the dominant healthcare professionals looking after this group, so the level of training in geriatric medicine and geriatric nursing does not necessarily equate with the actual population of people that they care for.’

Dr Bollen suggests that more training in geriatric medicine for GPs to upskill every two years, similar to requirements in cardiopulmonary resuscitation (CPR), could be beneficial.

‘Every healthcare professional is going to be working with older people, so we shouldn’t limit geriatric training to one specialty group [geriatricians],’ he said. ‘The actual understanding of the concerns of multimorbidity, polypharmacy and functional decline need to be in everyone’s curriculum, whether you’re a surgeon, psychiatrist or a GP.

‘The single-disease/single-organ specialists who are only focused on that one area … may be unaware of some of the contraindications [in older people].’

Prof Pond also recognises the significance of more education in treating older patients, as well as how all providers could benefit from increased communication and a greater understanding of how others are delivering care.

‘[GPs are likely to refer older patients to] various specialists – cardiologists, gastroenterologists, endocrinologists – for conditions which are quite common as you get older,’ she said. ‘Specialists don’t necessarily know what the others are doing or thinking.

‘[For example], a lot of medications have an effect on other parts of the body that the specialist might be looking at, so [understanding] medications is really important.

‘Psychosocial information is also very important, particularly in light of the fact a lot of older people are living on the pension. Most of them are not very well off and I think a specialist ought to know that.’

Those psychosocial factors can also include situations in which an older patient receiving care is a carer themselves. According to Dr Bollen, practitioners can take this type of scenario into account when liaising with different aged care providers so, in the event something goes wrong with an older patient who is looking after another person, both are still provided with appropriate care.

‘For example, when an 88-year-old patient is the carer for her 90-year-old husband, who is at home requiring 24-hour care,’ he said. ‘If the healthcare system is unaware that’s what’s happening … and a safety net has not been put in place to allow her to get the care she needs, then they will both go down.

‘These are the things that are increasing, because we know there are many older people who are dependent on a carer at home.’

Dr Bollen believes the responsibility ultimately lies with everyone involved in caring for older people, but GPs are in the best position to begin a quality healthcare journey.

‘When GPs are taking responsibility for older people in our practices, we’ve got to be mindful of trying to support the best care available for patients,’ he said. ‘GPs’ letters need to provide wraparound care to help communicate all of the issues that need to be discussed.

‘It’s got to be a culture where people are aware that communication is fundamental to good outcomes.’