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Referral - Synthesis

Introduction

An effective referral system ensures a close relationship between all levels of the health system and helps to ensure people receive the best possible care closest to home. It also assists in making cost-effective use of hospitals and primary health care services. Referral systems should enable people to receive optimal care at the appropriate level. Within a system framework, referral requires consideration of all parts and may be adjusted for the local circumstance. Criterion to guide referral is important as is the referral process. Referral processes will also need to comply with funding and legislative requirements. [1]

Quality Statement

This synthesis utilised evidence from twelve reviews and evaluations. Seven reviews dealt primarily with topics relating to palliative care [2-7] only while five dealt with aged care. [8-11] The overall quality of the systematic review evidence was good with appropriate searches and methods for extraction and analysis. Two international consensus papers [12,13] and other sources were included to provide context. [1,14-18]

Value of referral

The likelihood of a person dying in their preferred location can be influenced by modifiable factors such as early referral to palliative care and the presence of a multidisciplinary home palliative care team. [8]

Consideration of options

Recognising the need or treatment preference for palliative care can be difficult. [14] The concept of transition within palliative care is ill-defined and there is no accepted definition in this context. [2] Their review noted that the majority of studies acknowledged that the transition to palliative care could be improved. They saw that one of the challenges was in sensitively managing potentially abrupt change in care provider, care location and care goals that accompany referral to specialist palliative care.

Ensuring appropriate care can sometimes require that the whole context of treatment is considered. One review found that treatment options including the choice of less intensive treatments occurred after geriatric evaluation. [9] Other reviews have also acknowledged the role that geriatric assessment can have on clinical outcomes for patients and clients. [10] Geriatric evaluation may be an important aspect in considering whether active treatment as opposed to referral for palliative care is initiated.

Early integration of palliative care

Decisions about referral must consider both the person’s physical symptoms and their psychological and emotional readiness to receive palliative care. [1] Referral pathways and guidelines foster care integration which in turn improves quality of life, service coordination, efficiency and satisfaction with care, and reduces aggressive or non-beneficial therapies at the end of life, [1,12] Localised palliative care and advance care planning pathways are divided by geographical area in Australia and are available from local PHNs. The pathways are designed and written for use during the consultation and provide clear concise guidance for patient assessment, management, and referral to local health services. [15]

Timing of referral is an important issue. [1,14] A review of randomised controlled trials (RCTs) examining the integration of palliative care earlier in the course of the disease trajectory for patients with serious illnesses as an outpatient and at home showed a range of advantages including improvement in certain symptoms such as depression, improved patient quality of life, reduced aggressive care at the end of life, increased advanced directives, reduced hospital length of stay and hospitalisations, improved caregiver burden and better maintenance of caregiver quality of life and reduction in the medical cost of care as well as patient and family satisfaction. One of the challenges in the review was the definition of early palliative care. [3] Other work has also shown that early palliative care improves the main outcomes of the assistance in patients with advanced oncologic and non-oncologic chronic diseases. [4]

Referral criteria

Establishing referral criteria requires an understanding of who are the appropriate candidates for palliative care and what is the optimal timing remains unclear. Their review identified 20 criteria including 6 recurrent themes for outpatient palliative cancer care referral and represents an initial step toward developing standardised referral criteria. [5,13] The six major categories for referral criteria included physical symptoms, cancer diagnosis, prognosis, performance status, psychosocial distress, and end-of-life care planning. The authors noted that more work is needed to define the most appropriate assessment tools and optimal cut-offs for routine screening and referral. Referral criteria also needs to be tailored to the local institution and should complement, instead of replacing, clinical judgment to facilitate appropriate referrals. A separate review also indicated that increasing use of palliative care/hospice services required the identification of appropriate hospice candidates and a process of referral that was feasible in the context of the referring system. [6]

An international representative Delphi study has recently defined eleven major criteria for referral: severe physical symptoms, severe emotional symptoms, request for hastened death, spiritual or existential crisis, assistance with decision making or care planning, patient request for referral, delirium, spinal cord compression, brain or leptomeningeal metastases, within 3 months of advanced cancer diagnosis for patients with median survival of 1 year or less, and progressive disease despite second-line therapy. [13] The presence of any major criterion alone could be sufficient to trigger an outpatient palliative-care referral. The experts noted that given that resources are often limited in reality, these criteria would need to be further customised before application at the institution level. [13] Although these criteria have been developed within the cancer context, many could be applied to non-cancer diagnoses.

Referral processes for aged care

Referrals to aged care services in Australia are handled though a web form held on the My Aged Care website. This enables the collection of professional information to support the older people’s access to aged care services. Aged care assessment teams (ACATs) often link older people with appropriate aged health services in their local community. These may include Commonwealth-funded and non-Commonwealth-funded services. In some cases, the assessor may monitor referral to ensure that an effective referral has been made. [16]

A review undertaken by Heath Quality Ontario looked at evidence-based criteria regarding when to refer a person for home care services. They found that the criteria for accepting referrals were not always clear. They found that older people and those with major mobility limitations, longer hospital stays, and more co-morbidities were more likely to be referred to home care than those whose needs may be less obvious. [17]

Other issues

For older Australians who are admitted to hospital, rapid response team (MET) can influence end-of-life care through end-of-life (EoL) discussions. For patients seen by MET there were fewer ICU transfers, increased palliative services and more patients who died within 24 hours. [18] Similar benefits have also been seen with quality improvement palliative care interventions in Emergency Departments (EDs). [7] When palliative care referrals are made in ED the time to the first palliative care consultation is shorter than via primary care or outpatient care. [7] 

Enhancing EoL quality will require multi-tiered interventions enacted through institutions, clinicians and patient/families. [12,18]

Work by Friedman et al. suggests that intellectually disabled ageing adults may be at particular risk of non-referral for needed services. [11]

Education of doctors is particularly important for the timely referral for palliative care services. [6,12]

Evidence Gaps

  • There is no agreed set of criteria or processes for referral to palliative care in Australia.
  • Most work around criterion for palliative care referral has come from the cancer field and may not be transferable to the aged care context. Criterion that are relevant to older people and to aged care settings are needed.
  • The role of palliative care needs in terms of referrals to residential aged care or for home care packages also needed to be considered. 
  • There has been little consideration of self-referral within the literature although in some states it is possible to self-refer to palliative care.
     

Page updated 01 July 2021

  • References

  1. Palliative Care Australia. Background Report to the Palliative Care Service Development Guidelines (741kb pdf). Canberra (ACT): Palliative Care Australia; 2018.
  2. Gardiner C, Ingleton C, Gott M, Ryan T. Exploring the transition from curative care to palliative care: a systematic review of the literature. BMJ Support Palliat Care. 2011 Jun;1(1):56-63.
  3. Davis MP, Temel JS, Balboni T, Glare P. A review of the trials which examine early integration of outpatient and home palliative care for patients with serious illnesses. Ann Palliat Med. 2015 Jul;4(3):99-121.
  4. Tassinari D, Drudi F, Monterubbianesi MC, Stocchi L, Ferioli I, Marzaloni A, et al. Early Palliative Care in Advanced Oncologic and Non-Oncologic Chronic Diseases: A Systematic Review of Literature. Rev Recent Clin Trials. 2016;11(1):63-71.
  5. Hui D, Meng YC, Bruera S, Geng Y, Hutchins R, Mori M, et al. Referral criteria for outpatient palliative cancer care: A systematic review. Oncologist. 2016 Jul;21(7):895-901. Epub 2016 May 16.
  6. Kirolos I, Tamariz L, Schultz EA, Diaz Y, Wood BA, Palacio A. Interventions to improve hospice and palliative care referral: a systematic review. J Palliat Med. 2014 Aug;17(8):957-64. Epub 2014 Jul 7.
  7. Wilson JG, English DP, Owyang CG, Chimelski EA, Grudzen CR, Wong HN, et al. End-of-Life Care, Palliative Care Consultation, and Palliative Care Referral in the Emergency Department: A Systematic Review. J Pain Symptom Manage. 2020 Feb;59(2):372-383.e1. doi: 10.1016/j.jpainsymman.2019.09.020. Epub 2019 Oct 3.
  8. Costa V, Earle CC, Esplen MJ, Fowler R, Goldman R, Grossman D, et al. The determinants of home and nursing home death: a systematic review and meta-analysis. BMC palliative care. 2016 Jan;15:8.
  9. Hamaker ME, Schiphorst AH, ten Bokkel Huinink D, Schaar C, van Munster BC. The effect of a geriatric evaluation on treatment decisions for older cancer patients--a systematic review. Acta Oncol. 2014 Mar;53(3):289-96.
  10. Deschodt M, Flamaing J, Haentjens P, Boonen S, Milisen K. Impact of geriatric consultation teams on clinical outcome in acute hospitals: a systematic review and meta-analysis (Provisional abstract). BMC Med. 2013 Feb 22;11:48
  11. Friedman SL, Helm DT, Woodman AC. Unique and universal barriers: hospice care for aging adults with intellectual disability. Am J Intellect Dev Disabi. 2012 Nov;117(6):509-32.
  12. Payne S, Hughes S, Wilkinson J, Hasselaar J, Preston N. Recommendations on priorities for integrated palliative care: transparent expert consultation with international leaders for the InSuP-C project. BMC Palliat Care. 2019 Apr 3;18(1):32. doi: 10.1186/s12904-019-0418-5.
  13. Hui D, Mori M, Watanabe SM, Caraceni A, Strasser F, Saarto T, et al. Referral criteria for outpatient specialty palliative cancer care: an international consensus. Lancet Oncol. 2016 Dec;17(12):e552-e9.
  14. Palliative Care Australia (PCA). Palliative Care Service Development Guidelines (340kb pdf). Canberra: PCA; 2018.
  15. Royal Australian College of General Practitioners (RACGP). RACGP aged care clinical guide (Silver Book). Melbourne: RACGP; 2019 [updated 2019 Sep 5; cited 2021 Jul 1].
  16. Australian Government. My Aged Care Assessment Manual (472kb pdf). Canberra: Department of Health; 2018. 20 p.
  17. Health Quality Ontario. Criteria for referral to home care: a rapid review. Toronto: Health Quality Ontario. 2015; (4). 
  18. Tam B, Salib M, Fox-Robichaud A. The effect of rapid response teams on end-of-life care: a retrospective chart review. Can Respir J. 2014 Sep-Oct;21(5):302-6.