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UC-04: Referral to Central Access and Triage (CAT)

Description

Requester Health Care Provider sends a referral request to Central Access and Triage, which manages the referral process

Notes:

• A Central Access & Triage (CAT) model to manage eReferrals may be implemented (provincially, regionally, or locally at organization level) and/or for specific health care specialties/services.
• While a Central intake model may primarily focus on administrative processing/scheduling, the CAT model incorporates more comprehensive clinical triage and care coordination processes. Protocols and clinical pathways, developed with input from the health care providers, guide the referral processes.
• When a CAT model is used, all referral status events flow back to Central Access & Triage (CAT) as the owner/manager of the entire referral journey. CAT manages the status of the central (provincial) record and communicates information back to the referring provider as workflow progresses through a central RMS system.
• This use case assumes that all participants are integrated for electronic message flows; however the workflow requirement allows for both integrated and non-integrated communications (e.g. referral record could be sent via e-fax or other channel).

Scenario

Jayanti is a retired professional athlete. During her career, she experienced a number of injuries which has led to chronic pain challenges. Despite efforts with physiotherapy and medication, the pain in her right shoulder has worsened. Recent imaging (x-ray, ultrasound, and MRI within the past 12 months) has confirmed a deterioration in her condition. Several years ago, Jayanti found relief through joint injections administered by an orthopedic surgeon in another city (where she was previously living).

Based on established clinical pathways, Jayanti ’s family physician refers her to an orthopedic specialist for a reassessment and to explore appropriate options for alleviating her on-going discomfort, which may include potential joint injections.

The eReferral is submitted to the Central Access & Triage (CAT) centre. Upon receiving the eReferral, the CAT team reviews the request, prioritizes it based on clinical guidelines, creates a central referral record and assigns the request to an appropriate and available orthopedic specialist.

The medical office assistant at the orthopedic surgeon’s office is notified of the incoming referral request. After reviewing the request, the specialist decides to schedule an in-person appointment with Jayanti and his office assistant contacts Jayanti to schedule an appointment. Updates on the status of Jayanti’s referral is sent to the CAT. Jayanti’s family physician receives updates from the CAT when the appointment is scheduled and completed, to keep her informed about the referral status.

Participants

Please refer to Participants for definitions.

Use Case Actors/People	System
Requester Health Care Provider (HCP)	Source System (POS or RMS)
Performer HCP	Target System (POS or RMS)
Central Access & Triage (CAT) team/Case Assigner	Central System (RMS)

Pre-conditions

• The Source System is integrated with a valid and up-to-date Health Services Directory. The Health Service Directory can be provided by the Jurisdiction/ region (e.g., CAT services catalogue in Alberta) and define specialty/subspecialty and/or reason for referral.
• Appropriate patient consent in accordance with jurisdictional requirements and legislation, whether implied or expressed, has been obtained to share their personal and health information during the referral process.
• Patient information in Requester POS system is valid
• The Requester Source system has the ability to submit eReferrals in the prescribed format.
• The Performer Target system has the ability to receive and respond to eReferrals in the prescribed format.
• The Performer HCP has registered as a service provider for centrally managed referrals.

Post-conditions

• Primary Flow: The Performer HCP completes the requested service and CAT closes the referral;
• Alternate A: The Performer HCP declines the referral request and CAT closes the referral.
• Alternate B: CAT cancels the referral without assigning it to a Performer HCP;
• Alternate C: The Performer HCP cancels the referral request after it was accepted, and CAT closes the referral
• Alternate D: The Requester HCP revokes the referral request and CAT closes the referral.

Workflow diagram

This use case diagram represents the participants and their role in the use case with a high-level view of the clinical and information workflow.

Please see Sequence Diagrams for UC-04: Central Access and Triage (CAT) for a technical sequence diagram implementing this use case.

Primary Flow

The following provides a textual description corresponding to the use case diagram.

1. The Requester HCP initiates a referral request.
2. The Requester HCP searches for and selects the appropriate service (based on results from the Health Service Directory). Available options may be based on reason for referral. There may be an option to indicate a preferred service provider/location or indicate dissent to assign a specific provider (e.g., based on patient preferences).
3. The Requester HCP completes the information needed for the requested service.
4. The Requester HCP submits the referral request to CAT. The Requester (Source System) transmits the eReferral to the CAT (Central System).
5. CAT receives the request and creates the central referral record in the Central System. CAT communicates the shared referral identifier with the Requester HCP.
6. CAT reviews the request for adherence to business rules for referral contents.

• If CAT needs additional information, see Additional Flow i

7. CAT assigns the request to an appropriate Performer HCP and the Central System sends the referral record to the Performer HCP

8. CAT notifies the Requester HCP that the referral record is now updated with the Performer assignment.

9. The Performer HCP acknowledges receipt of the newly assigned referral request. Performer Target System initiates the corresponding Performer workflow.

10. The Performer HCP reviews the referral request.

• If Performer HCP requests information from the Requester HCP, see Additional Flow ii

11. Performer HCP agrees to perform the requested service.

• If the Performer HCP declines the request, see Alternate Flow A.

12. CAT receives the accepted status from the Performer HCP, and updates the state of the central referral record as applicable.
13. CAT notifies the Requester HCP that the referral record is now updated with a status indicating acceptance by the Performer HCP.
14. The Performer HCP schedules the appointment for the patient consultation, and the Target System sends the appointment details to the CAT Central System.
15. CAT receives the appointment details from the Performer HCP, and updates the state of the central referral record as applicable.
16. CAT informs the Requester HCP of the scheduled appointment.
17. The Performer HCP fulfils the requested service through the patient consultation appointment, and notifies CAT that the performer workflow is complete.
18. CAT receives the completed status from the Performer HCP, and updates the state of the central referral record as applicable.
19. CAT notifies the Requester HCP that the referral record is now updated with a status indicating completion of the requested service.

Additional Flows

The following are extra steps/processes that may be added to the primary workflow to handle specific circumstances or requirements.

i. CAT requests additional information from Requester HCP (after step 6 and before step 7)

• The CAT needs more information from the Requester HCP before they can assign the request to the Performer HCP.

1. CAT documents the additional information needed, and sends the information request to the Requester HCP.
2. Requester HCP receives the request and gathers the information needed.
3. Requester HCP updates the service request with the additional information (e.g. attached supporting info) and/or separately documents a communication containing their response; then sends the assembled response to CAT.
4. Use case flow returns to step 7 of the primary flow, for assignment of the Performer HCP.
   

ii. Performer HCP requests additional information from Requester HCP (step 10)

• The Performer HCP needs more information from the Requester HCP.

1. Performer HCP documents the additional information needed and sends the information request to CAT to manage as part of the central referral record.
2. CAT receives the information request from the Performer HCP, and updates the state of the central referral record as applicable.
3. CAT incorporates any centrally managed information to the Performer HCP information request as needed, and sends to the Requester HCP for response.
4. Requester HCP updates the service request with the additional information (e.g. attached supporting info) and/or separately documents a communication containing their response; then sends the assembled response to CAT.
5. CAT receives the information response from the Requester HCP, and updates the state of the central referral record as applicable.
6. CAT sends the response information to the Performer HCP.
7. Use case flow returns to step 10 for the performer to review and resume related workflow.
   

iii. CAT redirects referral request to a new Performer HCP (see Alternate Flow B)

• CAT may redirect the case to a different Performer HCP. Reasons for this can vary and may include case declined by Performer HCP. This does not close the referral request but rather redirects it to a new Performer HCP.

1. CAT receives the declined information from the Performer HCP that indicates they cannot fulfill the request as assigned.
2. CAT identifies an alternate service provider for the referral request, and replaces the assigned Performer HCP.
3. Use case flow returns to step 7 of the primary flow, where workflow re-starts under the new performer.

Alternate Flows

The following are processes/pathways that achieve a different outcome from the primary workflow based on specific circumstances or requirements.

A. Request declined by Performer HCP (step 8)

• The Performer HCP decides to decline the referral request after reviewing it. The Performer HCP updates the referral status and includes a reason for declining the request (e.g., unable to provide the service) in the Target System. An update is sent to CAT.

1. Performer HCP determines either that the service cannot or should not be fulfilled as requested, or that the referral request is appropriate but cannot be fulfilled as assigned; then notifies CAT of the declined request along with details of the reason for declining.
2. CAT receives the declined information from the Performer HCP, and updates the state of the central referral record. If the request is redirected to a new performer, see Additional Flow iii
3. CAT notifies the Requester HCP that the referral record for the referral request has now been updated to indicate a declined service, including the decline reason.