Referral - Synthesis

Referral - Synthesis


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.

Quality Statement

This synthesis utilised evidence from twelve reviews and evaluations. Seven reviews dealt primarily with topics relating to palliative care only while five dealt with aged care. The overall quality of the systematic review evidence was good with appropriate searches and methods for extraction and analysis.

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. [1]

Consideration of Options

Recognising the need or treatment preference for palliative care can be difficult. 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. [3] Other reviews have also acknowledge the role that geriatric assessment can have on clinical outcomes for patients and clients. [4] 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

Timing of referral is an important issue. 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. [5] 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. [6]

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. [7, 8] 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 replace, 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. [9]

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. 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. [8] 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.

 A review undertaken by Heath Quality Ontario looked at evidence-based criteria regarding when to refer a patient for home care services. They found that the criteria for accepting referrals were not always clear. They found that older patients 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. [10]

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 these patients there were fewer ICU transfers, increased palliative services and more patients who died within 24 hours. Enhancing EOL quality will require multi-tiered interventions enacted through institutions, clinicians and patient/families. [11]

Work by Friedman et al. suggests that intellectually disabled ageing adults may be at particular risk of non-referral for needed services. [12]

Education of doctors is particularly important for the timely referral for palliative care services. [9]

Evidence Gaps

  • There is not yet an agreed set of criteria or processes for referral to palliative care to promote 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 25 May 2017

  • References

  1. 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.
  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. 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.
  4. 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
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. Health Quality Ontario. Criteria for referral to home care: a rapid review. Health Technology Assessment Database [Internet cited 2017 May 24]. 2015; (4). 
  11. 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.
  12. 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.