Stay Looped In: Following-up With Patients You Refer Out

WUTZKOH / STOCK.ADOBE.COM

Getting patients on board with a referral to a specialist can be challenging. For many patients, getting into the dental chair in the first place can be a stressful experience—let alone being told they need to go somewhere else for additional treatment. For a hesitant patient, reaching out to a second office they are unfamiliar with for a procedure which they may be concerned will be painful, expensive or time-consuming, can be an intimidating or even overwhelming prospect.

“Let’s say a patient goes into a dental office and it was already hard to get into the chair to begin with,” says Sam Ahani, DDS, founder of Refera. “And the dentist says, you’re going to need to see an endodontist, or need this additional treatment that you’ll have to see a specialist for. And then they hand you a paper referral. How much motivation is it going to take now to call a second office that you aren’t familiar with? You don’t know if it’s going to hurt, how much it’s going to cost—you don’t know anything about the other side. There’s a good chance you won’t do it.”

Many patients leave that situation feeling unmoored and unsupported by the dentist, particularly if the need for treatment or reasoning for the referral hasn’t been effectively communicated.

“With practice owners and dental teams being so busy, sometimes there is a lack of communication with patients as to why multi-step treatment is needed,” says Andrea Gallimore, product manager for Henry Schein One. “It ultimately benefits the practice to take the time to educate patients and thoroughly address the patients’ needs and concerns. It is so important for practitioner to build that patient relationship.”

A lack of clear communication or support in connecting a patient with a specialist often manifests into a lack of follow-through with scheduling an appointment. In fact, Dr Ahani says, he’s found that when patients are simply given a paper referral form and are told to call to make an appointment, about 30 to 40 percent of patients fail to do so. Compound that with a lack of follow-up from your office, and not only will patients not get the recommended treatment, but they also may not return to your practice.

“If the patient doesn't go to the specialist, there’s a good chance that they aren’t going to come back to you either,” Dr Ahani says. “Because you referred them out for something but you didn’t follow up and they didn't follow through. And they know you're going to ask them about it if they come back for another visit, so a lot of times they don't come back to you at all.”

So where does that leave clinicians? On the clinician’s end, unstructured (or nonexistent) referral channels and a lack of tracking and follow-up all hinder a successful referral process and can have a negative impact on patient care, with far-reaching implications.

“Patients not returning hurts a dental practice,” Gallimore says. “When patients don’t follow through on their treatment plan, the repercussion is twofold: The patient is potentially putting their oral health at risk, and the practice loses production. It also can potentially impact a practice’s reputation if there’s a lack of patient communication.”

Referral Challenges

When it comes to referrals, the challenges don’t only apply internally to the dental industry. One survey found that in the past year, 52 percent of physicians reported not referring patients to a dentist for oral-health concerns due to a lack of an available referral system. Of the physicians that did refer patients to a dental specialist, 70 percent allowed the patient to contact a dentist on their own rather than providing a formal referral to a specific dentist.¹ This put the onus of receiving follow-up care completely on the patient.

“The cycle is broken,” Dr Ahani says. “What should happen is that the specialist should reach out and schedule you. When a dentist refers out, oftentimes they think, ‘my job is done.’ But your role isn’t really complete because there are still so many steps that should happen. Just handing them the paper referral, that job isn’t done.”

These steps can be cumbersome. Ideally, the dentist’s front desk should call that office informing them of the referral. The specialist will call the dentist’s office asking for X-rays and insurance information—or they call the patient asking for those things, and the patient has to call the office. Then the office should follow up with that patient in a few weeks to see if they have scheduled the care.

“But how are you going to follow up?” Dr Ahani asks. “Are you just going to call up the patient and say, ‘just wondering if you got that care?’ There’s only so much bandwidth in a dental practice and oftentimes there isn’t room for all those steps. Referrals are often out of sight, out of mind, but there are a lot of good reasons to track them.”

However, tracking efforts don’t always make the grade. Dr Ahani says he’s yet to speak to a dentist that can give him a report that shows who they’ve referred out in the past week, month, year, etc. They just aren’t keeping track—perhaps because they don’t have a streamlined way to do so.

“Clinicians don’t have a good way to track it in their practice management software, or even if there is that functionality, they aren’t using it,” Dr Ahani explains. “But whatever you do, just have a system. If you want to just write down in a list when you refer a patient out, do that.”

Dr Ahani even gives a nod to the “old days,” saying that they actually had a better system than we do now: In the past, referral slips used to be triplicate, so clinicians would put one on the chart, give one to the patient, and the third would be mailed to the specialist. While using snail mail to send referral slips to specialists may not be the most effective method of connecting with referral partners these days, Dr Ahani says any system is better than no system.

“Paper isn’t the greatest system, but if you have a system that works, use it,” Dr Ahani says. “If you want to track it in your practice management software, do that. But it’s a very good idea to track referrals.”

Luckily though, there are options available that are a little more advanced than just paper. Gallimore encourages practices to utilize the tools already available in their practice management systems.

“We often work with offices that do not have any protocols set in place to follow up with treatment that has been referred out, and in some cases, do not track those cases,” she says. “Practices need to use their practice management software’s capability for accurate tracking. Treatment planning the entire case—which would include procedures that are being referred out—is critical to establish standard operating procedures for follow up with patients.”

In addition to being able to provide better patient care by providing collaborative care alongside the specialist, good record keeping of referrals can have financial benefits for the practice. Tracking and staying on top of referrals allows practices to see who was referred out that maybe didn’t return to the practice, and assess how many patients are coming in versus being referred out.

“From a business standpoint, a lot of practices are sending out as many patients as they get new ones,” Dr Ahani says. “Maybe you’re getting 10 to 20 new patients a month, but you’re referring the same number out, but there's no tracking to see what happened to that patient to ensure they come back. Then we end up spending all that money on marketing to basically break even.”

When it comes to money, effective tracking can have big benefits for practices thinking about incorporating with a dental service organization (DSO). When a DSO first enters a practice, they want to know what a practice refers out, whether that be wisdom teeth, root canals, etc. DSOs generally want to bring those things in house, but want to know what sort of volume to expect.

“If you actually have reporting that shows you how much you refer out, I think your practice actually becomes much more attractive to those DSOs whose model is to bring specialists in, or have the dentist do the specialty work in-house,” Dr Ahani says. “You’ve already done the legwork for them.”

The Benefits of Going Digital With Referrals

Realistically, in a busy office, how can practices effectively track referrals in an organized manner that won’t eat up all of their staff’s time? Go digital. When referrals are done manually, there’s no easy way to track if the patient saw the referred specialist, or what the treatment outcome was if they did see the specialist. Communication via phone or fax between the referring practice and the specialist can be time consuming and information can be excluded or forgotten.

In a digital format, however, all the patient’s pertinent information can be transferred electronically and instantly, and be viewed by all the providers working on the case. This also eliminates the risk of illegible handwriting or jotting down the wrong tooth number in a rush with a paper referral, that can lead to more back and forth. There aren’t any forms that can get lost, and more information and documentation can be easily shared.

“Utilizing tools with the practice management system is key to success in tracking where a patient is within the treatment process,” Gallimore says. “Pulling reports routinely from the practice management software provides the practice with information they can then use to create a campaign for patients regarding outstanding treatment.”

Digital referral options are growing, with paperless practice- and referral-management software and platforms like Dentrix, Open Dental, Planet DDS, ReferralMD (for medical-to-dental referrals), OneClick, and Refera all offering various solutions for streamlining referrals in the dental field.

Refera, for example, offers a Health Insurance Portability and Accountability (HIPAA)-compliant online platform that allows dentists to refer patients to any other practice, regardless of whether or not that practice is on the platform. Dr Ahani likens the Refera platform to Dropbox: Anyone can send or view a file on the platform, whether or not they have an account—a far cry from other platforms that require both practices to be on the same system.

Through Refera, dentists can send (and receive) referrals, transfer files, and, importantly for the referring doctor, view the referral status through the simple and intuitive interface. After the referral has been sent, its progress is tracked by the system, and the doctor can see if and when the appointment was scheduled, and subsequently, when the treatment is completed.

“When a specialist receives a referral, there’s a note that says the referring doctor is requesting you contact this patient,” Dr Ahani explains. “And there’s a little countdown timer until you schedule, and once the specialist has scheduled the appointment, they can press the ‘Schedule’ button and both sides can now see that the patient has been scheduled.”

This lets the referring doctor know that the referred patient is at least scheduled to see the specialist, removing any of the will they/won’t they doubt and eliminating any need for the referring doctor to follow up to inquire about the status of an appointment.

The patient’s side of things is also streamlined. Rather than trying to dig up the paper referral that got buried at the bottom of a purse or used as a coaster, patients receive a text and/or email when the digital referral is created, containing all the specialist’s information. Updates about appointment time and date, or any other notifications, are also all transmitted digitally to the patient, reducing the likelihood of them forgetting about (or losing) the referral recommendation. Patients feel like their doctor is still in the loop on their care, and is invested in making sure they receive the necessary care.

This can build patient loyalty, and also assist doctors in providing more comprehensive care. Not only does it benefit individual patients, but also the practice, as lost referrals can result in lost revenue. By being able to track the status of referral appointments, dentists can see when it’s time to reach back out to the patients to ask about their care, establish further treatment plans, or set up recall visits.

Having all the referrals in one place such as the Refera platform also improves reporting and efficiency, Dr Ahani says. For smaller practices that only do 10 to 20 referrals a month, the free platform that is not integrated into the practice’s practice management program works well. For larger practices that refer out a lot of patients, there is a premium integrated version that pulls information directly from practice management software, further streamlining the workflow.

“For those practices that have a lot of referrals, we recommend that they get the integrated version,” Dr Ahani says. “The advantage of it mostly is that it's very easy; you see the patient's name on the schedule, you click on it and everything uploads, including the insurance information.”

When it comes to integration, many users may not be aware that referral tools may already be available in their current practice management software. For instance, Dentrix has a referral tracking model that allows practices to see where the patient is within the treatment process and referrals to other providers.

“Along with this tool, communicating with patients through tools such as Lighthouse 360, (particularly the Campaign Studio feature) emphasizes the importance of the treatment, and can even remind the patient to contact the referred provider for treatment,” Gallimore explains.

Gallimore notes that the Henry Schein One practice management solutions, such as Lighthouse 360, offer a Campaign Studio feature, that provides practices with the option to create campaigns to stay in touch with patients that have outstanding treatment and remind them of the importance of dental health. Utilizing the Campaign Studio feature also gives practices the ability to send educational information to patients encouraging them to stay on track with treatment.

“Having tools in the practice that integrate help to build efficiencies in the practice and more streamlined ways of contacting patients,” Gallimore says. “Automated reminders, patient forms, newsletters, reviews, online booking, and much more enable practices to focus on treatment and getting patients back in the door.”

Another referral-tracking option hit the market last year when Planet DDS launched 2 new referral features for its Denticon software. The first, the Internal Referral Management System, is aimed at DSOs and multi-location or multi-specialty dental practices to help streamline referrals within the group. When a patient needs a referral to another specialty, the treatment coordinator can easily pull up a list of specialists within the DSO’s network, and sort by proximity to the patient’s home address. Schedulers can view the specialist’s availability through the system and schedule an appointment on the spot. They can even view the specialist’s fee schedules within their group to create a comprehensive treatment plan they can present to the patient.

Personal health information and X-rays can then be sent instantly through Denticon to the specialist so they have all the pertinent details before the patient ever arrives. The patient just has to show up for their appointment, with no unnecessary back and forth over appointment times or file transfers.

For non-DSOs or groups, Planet DDS also launched the External Referral Management System. This allows practices to refer patients and communicate with external specialists, whether or not the specialist is a Denticon subscriber. When a practice refers a patient to a specialist, the specialty practice receives a verification email. Once the specialist verifies the email, they can access the secure external eReferral portal, where they can send and receive personal health information, images and X-rays, and other files securely and in compliance with HIPAA and patient privacy laws.

Like Refera and other digital platforms, the Denticon referral tools eliminate the need for extra time-consuming communications with the specialist to follow up on the status of a referral, or share information and treatment plans. Referrals are instantly transmitted, and the 2 practices can communicate through the eReferral portal. Specialists can report back to the referring doctor with status updates, keeping the doctor in the loop throughout the entire process.

Staying In the Loop

In the end, regardless of which platform or method of tracking referrals you use, good communication between the practices, and between the practices and the patient, is critical.

“Patient communication is key to developing trust between the practitioner, the dental team, and patients,” Gallimore says. “A lack of patient communication can have serious consequences for their long-term oral health, increased costs with less favorable outcomes for both the patient and the dental team.”

And a crucial piece of this communication is staying involved with patients you’ve referred out and always remaining on top of your referrals.

“I think that managing your referrals is just a very important part of the practice,” Dr Ahani says. “And it’s a very simple thing—it's a very simple change to make and I think it’s critical.”

References

1. Miloro MB, Vujicic M. Physicians Dissatisfied with Current Referral Process to Dentists. American Dental Association Health Policy Institute. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/hpi/hpibrief_0316_5.pdf. Published March 2016. Accessed October 19, 2022.