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UC-03: Referral to Central Intake

UC-03: Description

Requester Health Care Provider (HCP) sends a referral request to Central Intake. Central Intake assigns the referral request to an appropriate and available Performer HCP.

Notes:

• A Central Intake model to manage eReferrals may be implemented (provincially, regionally, or locally at organization level) for specific health care specialties/services.

• When a central intake model is used for eReferrals, Central Intake serves as a centralized mechanism or intermediary to manage eReferral requests, ensuring incoming requests are assigned to an appropriate specialist/service provider. The Case Assigner at Central Intake may be a healthcare professional (e.g., nurse) trained to assess the urgency and appropriateness of referrals.

• Typically, Central Intake focuses on administrative aspects of handling eReferral requests). However, responsibilities of Central Intake can vary across jurisdictions/regions and may include ensuring completeness of referral requests, scheduling appointments, tracking and monitoring referral statuses, and supporting follow-up processes. In some cases, Central Intake may also include triaging/prioritizing request (based on urgency, clinical criteria, established protocols/clinical pathways), facilitating communications and information exchange between the referring provider and specialist/healthcare professional

UC-03: Scenario

Mary Jane had a ski accident. Her primary care provider, a family physician, strongly suspects that Mary Jane has torn her anterior cruciate ligament (ACL) in the right knee and would like to refer her for further assessment. The primary care provider creates an eReferral for Mary Jane, selecting the appropriate specialty (Orthopedics), service and reason for referral. The referral requirements are displayed on his screen, with some information already populated from Mary Jane’s electronic medical record (EMR). The family physician completes the remaining information needed for the referral. The referral request is submitted and received by Central Intake. Central intake assigns the request to a Performer HCP based on one of the following scenarios:

Option 1 (UC-03a): Central Intake forwards request to Performer HCP (Routing Request)

“Routing requests” refers to the process of directing or forwarding eReferrals to an appropriate healthcare provider or specialist. In this scenario, Central Intake receives the eReferral request and assigns it to a specialist based on availability and other relevant criteria, ensuring the referral is directed to the most suitable provider who can address the patient's condition or concerns effectively.

Central Intake receives a notification of the new eReferral request. The Case Assigner reviews the details and forwards the request to an orthopedic surgeon located a close distance to Mary Jane's home with the shortest wait time. The family physician receives a referral status update that the request has been sent to the specialist.

The specialist’s office receives a notification about the incoming referral request. After reviewing the request, the orthopaedist accepts the patient for treatment and the office staff book an appointment for Mary Jane. The family physician receives a referral status update that an appointment has been scheduled.

After the specialist has conducted the initial consultation appointment with Mary Jane, the family physician receives a status update that the appointment has been completed.

Option 2 (UC-03b): Subsequent referral linked to initial referral request (Chaining requests)

"Chaining requests" refers to a sequential referral process where subsequent referrals are connected or chained to an initial referral request.

In this scenario, Central Intake directs the referral to a Rapid Access Clinic/ Rapid Assessment Centre (RAC). If the assessment outcome indicates further services are needed, a subsequent referral (that is linked to the initial referral) is created by Central Intake for the additional services.

Notes:

• This example assumes referrals to RAC is sent through central intake. Depending on policies and processes established by the jurisdiction, region, and/or organization, requests to RACs may alternatively follow a direct referral pathway (i.e., request is sent directly to RAC and bypass Central Intake). If a direct referral pathway is used, see UC-01: Referral directly to a Service Provider.
• If Central Intake assigns the referral to a RAC, it is typically assigned at the facility level rather than at the individual level, and the RAC team (administrative and clinical staff) manage the intake process and subsequent assessment and treatment planning. The patient is assessed by a health professional with the required training and qualifications, who may be a nurse practitioner, a specialty provider (e.g physiotherapist), or other advanced practice provider.
• If results of the RAC assessment indicate the patient requires additional services from another provider (surgical or non-surgical), a new referral that is linked to the original request is created by Central Intake. Alternatively, depending on policies and processes established by the jurisdiction, region, and/or organization the RAC could create the new referral linked to the original request, and send it i) directly to a service provider, or ii) to Central Intake to assign a service provider.

Central Intake receives a notification of the new eReferral request. The Case Assigner at central intake forwards the referral to a Rapid Access Clinic/Rapid Assessment Centre (RAC) that serves the geographic area where Mary Jane resides.

The RAC staff triage and assign the referral to an appropriate and available healthcare provider (e.g., advanced practice provider within the RAC who will conduct the assessment. Administrative staff at the RAC schedule Mary Jane for an appointment.

Based on results of the assessment, Mary Jane is a potential candidate for surgery. The RAC sends an update to Central Intake that the assessment has been completed. The Central Intake creates a new referral, linked to the original request, and sends it to an orthopedic surgeon. An update is sent to the family physician that the original eReferral has been completed and a new referral has been created for Mary Jane.

Note: If a Central Access and Triage (CAT) model is used, the original request is deemed completed and an update is sent to CAT. A new referral, linked to the original request, is created by CAT and sent to an orthopedic surgeon. See UC-04: Referral to Central Access and Triage (CAT)

Option 3 (UC-03c): A single referral divided into multiple referrals (Splitting requests)

“Splitting requests” refers to the process where a single referral is divided or split into multiple referrals, each directed to a different providers or services.

In this scenario, the referral is received by Central Intake. Since more than one service is requested, the case assigner at Central Intake “splits” the request and assigns each service to a different site.

When completing requirements for the referral request, the family physician sees that diagnostic imaging results need to be included. The family physician creates a single eReferral for an MRI and an ultrasound and sends the request to Central Intake.

Central Intake receives a notification of the new eReferral request. The Case Assigner at central intake “splits” the request into separate referrals (MRI and ultrasound) and the requests are sent to two different diagnostic imaging sites.

At the respective diagnostic imaging facilities, the administrative staff receive a notification about the incoming request and schedule an appointment with Mary Jane. Updates for each referral are sent to Central Intake and the family physician when appointments are scheduled as well as when each appointment is completed.

UC-03: Participants

People	System
Requester Health Care Provider (HCP)	Source System (POS or RMS)
Performer HCP	Target System (POS or RMS)
Central Intake team/ Case Assigner	Central System (RMS)

Please refer to Participants for definitions.

UC-03: Triggers

Requester HCP needs to refer a patient for services with another provider (e.g., specialty care).

UC-03: Pre-conditions

• The Source system/Target system used by the healthcare provider is a) the point of Service (POS) system that includes RMS capability, or b) a standalone Referral Management System (RMS) that is integrated with the POS system.
• The Source system is integrated with a valid and up-to-date Health Services Directory
• 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.
• The Requester Source system has the ability to submit eConsults in the prescribed format.
• The Performer Target system has the ability to receive and respond to eConsults in the prescribed format.
• Patient information in Source system is valid.
• The Performer HCP has registered as a service provider for centrally managed referrals.

UC-03: Post-conditions

• Primary Flow: The Performer HCP completes the service and the eReferral request is closed.
  • UC-03a (Routing): Performer HCP completes the initial consultation appointment with the patient.
  • UC-03b (Chaining): The rapid assessment centre/ rapid access clinic (RAC) completes the assessment appointment with the patient. If the patient requires additional services, a new referral that is linked to the initial request is created.
  • UC-03c (Splitting): All the requested services on the initial referral have been completed.
• Alternate A: Central Intake declines the referral request; or
• Alternate B: The Performer HCP declines the referral request;
• Alternate C: The Performer HCP converts the referral to a consultation;
• Alternate D: The Requester HCP revokes the referral request;
• Alternate E: The Performer HCP cancels the referral request;
• Alternate F: Based on outcomes of the RAC assessment, the patient does not require additional services (only applicable to UC-03b)

UC-03a/c: CENTRAL INTAKE – ROUTING/SPLITTING REQUESTS

• Routing: The referral request is forwarded to a Performer HCP (downstream service).
• Splitting: The referral request contains request for multiple services and is split into different referrals at Central Intake. Each referral corresponds to the original request and is directed to different Performer HCPs (downstream services).

UC-03a/c (Routing/Splitting Requests): Workflow Diagram

This use case diagram represents the participants and their role in the end-to-end use case with a high-level view of the flow of information. Additional downstream services may be required beyond the initial workflow depicted in the diagram below. A routed or split referral may be followed by successive chaining, routing, or splitting operations at each subsequent downstream service, as necessary, to fulfill the original referral.

Please see Sequence Diagrams for UC-03: Referral to a Central Intake for a technical sequence diagram implementing this use case.

UC-03a/c (Routing/Splitting Requests) - 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). There may be the option to select a preferred service provider (e.g., organization, specialist).

3. The Requester HCP is presented with and completes the referral requirements. Patient information and referral requirements may be automatically populated based on information available in the POS system.

4. The Requester HCP may provide a clinical narrative to support the reason for the referral and/or attach additional clinical notes/supporting documentation from the POS system to support the referral request.

5. The Requester HCP submits the referral request with the required information and clinical documentation to Central Intake. The Source system transmits the referral request to the Central System.

6. Central System receives the referral request. The Case Assigner at Central Intake is notified of the new referral request.

7. The Case Assigner at Central Intake processes the referral request. This may include reviewing the referral details, triaging/prioritizing the request (based on urgency, clinical criteria, established protocols/clinical pathways, etc.) and determining the most appropriate healthcare provider for the request (based on wait times, location, patient preference, etc.).

8. The Case Assigner at Central Intake determines if the referral request needs to be split.

   1. If the eReferral request is to be completed by the same service provider (individual or organization), it is routed to the appropriate Performer HCP (UC-03a).
   2. If the eReferral request needs to be completed by multiple service providers, the Case Assigner may split the request into separate referral requests, one for each service. (UC-03c).

   Note: If the original eReferral was split into multiple requests, steps 9 to 12 are completed for each referral request.

9. The Case Assigner at Central Intake forwards the request to the appropriate Performer HCP. The Central System transmits the request to the Performer Target system and sends an update to the Requester HCP.

   Note: If the eReferral request, is forwarded to a Rapid Assessment Centre/ Rapid Access Clinic (RAC), the RAC is the Performer HCP (see primary workflow for UC-03b below).

10. The Performer Target system receives the referral request. The Performer HCP receives a notification about the new referral request and reviews it.

11. The Performer HCP accepts the request, and an appointment is booked with the patient. After the appointment is scheduled, the Performer Target system transmits an update to the Central System, which then forwards the update to the Requester Source system. The Requester HCP receives an update that the appointment has been booked.

    If the Performer HCP declines the request, see Alternate Flow B.

12. Performer HCP completes the appointment with the patient and closes the eReferral request. The Performer Target system transmits an update to the Central Intake, which then forwards the update to the Requester Source system. The Requester HCP receives an update that the appointment/service has been completed.

UC-03b: CENTRAL INTAKE – CHAINING REQUESTS

Chaining: After a referral request is completed and the patient needs further services, a subsequent referral (based on the original eReferral) is created and sent to the additional Performer HCP.

UC-03b (Chaining Requests): Workflow Diagram

This use case diagram represents the participants and their role in the end-to-end use case with a high-level view of the flow of information. Additional downstream services may be required beyond the initial workflow depicted in the diagram below. A routed or split referral may be followed by successive chaining, routing, or splitting operations at each subsequent downstream service, as necessary, to fulfill the original referral.

Please see Sequence Diagrams for UC-03: Referral to a Central Intake for a technical sequence diagram implementing this use case.

UC-03b (Chaining Requests): Primary Flow

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

Complete Steps 1 to 8 in UC-03a/c Primary Flow (see above)

9. If the eReferral request, based on established protocols and pathways, requires an assessment to be completed by a Rapid Assessment Centre/ Rapid Access Clinic (RAC), Central Intake forwards the request to the appropriate RAC (UC-03b)

   In this scenario, the RAC is the Performer HCP

10. The RAC (Target system) receives the referral request. The Performer HCP at the RAC receives a notification about the new referral request and reviews it.

11. The Performer HCP accepts the request and assigns it to a health care professional (such as an advanced practice practitioner) at the RAC who will conduct the patient assessment. The RAC books an appointment with the patient. After the appointment is scheduled, the RAC (Target system) transmits an update to the Central System, which forwards to the Requester Source system. The Requester HCP receives an update that the appointment has been booked.

    If the RAC declines the request, see Alternate Flow B.

12. The RAC completes the assessment appointment with the patient and indicates whether additional services (surgical or non-surgical) is needed. The RAC (Performer Target system) transmits an update to the Central System, which forwards to the Requester (Source system). The Requester HCP receives an update that the appointment has been completed.

13. If the patient requires additional services, the Central Intake creates a new referral (linked to the original request) for the subsequent service directly to the service provider (see UC-01: Referral directly to a Service Provider). Updates about the new referral are sent to the Requester HCP.

    If no additional services are required, see Alternate Flow F.

    Note: Depending on established protocols and pathways and the capabilities of the RAC Target System, the new linked referral may be created at the RAC.

UC-03: Additional Flows

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

i. Central Intake needs additional information (after step 6 and before step 9)

The Case Assigner at Central Intake requests more information from the Requester HCP (sent from the Central System to the Requester HCP). The Requester HCP updates the eReferral with the requested information. The update is sent to the Central System and accessed by the Case Assigner.

ii. The Performer HCP needs additional information (after step 10 and before step 11)

The Performer HCP requests more information from the Requester HCP before they can decide whether to accept the referral. The Performer HCP and Requester HCP systems have the ability to communicate and send questions/additional information. The request for information is sent to Central Intake. Central Intake forwards the request to the Requester HCP. When Central Intake receives an update/response from the Requester HCP, the new information is forwarded by Central Intake to the Performer HCP.

iii. Updates to the referral request (after step 5 and before Step 12)

The Performer HCP, Requester HCP and/or Central Intake may update the referral request after it is submitted to Central Intake and before the Performer HCP completes the service. This may include sending communications, updating the referral request with new information, etc.

iv. The appointment scheduled with the Provider HCP is changed (after step 11 and before step 12)

The appointment may be rescheduled due to patient preference or at the discretion of the provider HCP. When the original appointment is rescheduled, the Performer HCP updates information in the Target system. The Performer (Target system) transmits an update to the Central Intake (Central System) which forwards to the Requester (Source system). The Requester HCP receives an update that the appointment has been completed.

UC-03: 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 Central Intake (after step 7 and before step 8)

The Case Assigner at Central Intake declines the referral request after reviewing it. The Case Assigner updates the referral status and includes a reason for declining the request (e.g., unable to provide the service) in the Central System. An update is transmitted to the Requester HCP (Source system).

B. Request declined by Performer HCP (step 11)

The Performer HCP declines 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 Performer Target system. An update is sent to the Central System.

Central Intake reviews the reason the request was declined. Central Intake may reassign the request to a different Performer HCP or cancel the request. The Central System sends the update to the Requester HCP (Source system).

C. Referral request changed to a Consult request by Performer HCP (step 11)

The Performer HCP decides to decline the referral request (e.g., does not schedule patient for an in-person appointment) but provides advice to the Requester HCP. If the Target System includes this functionality, the Performer HCP can convert the referral request to an eConsult.

Alternatively, the Performer HCP may decline the referral request and indicate an eConsult should be requested. Depending on established protocols, the Requester HCP or Central Intake may create the eConsult request.

D. Referral request cancelled/revoked by the Requester HCP (after step 5 and before step 12)

The Requester HCP may cancel/revoke the referral request after it is submitted to Central Intake and before the Performer HCP completes the appointment. Reasons can vary and may include patient preference, reassessment of patient needs, changes in medical status and/or clinical judgment/diagnosis, transfer of care to another provider or facility, or administrative reasons.

The Requester HCP updates the referral status is the Source system and an update is transmitted to Central Intake and the Target system. The Performer HCP receives an update that the eReferral has been cancelled

E. Referral request cancelled by Performer HCP (after Step 11 and before Step 12)

The Performer HCP cancels the referral request after accepting the patient. This can occur when the Performer HCP or patient decides to cancel the request after it has been initiated but before the referral/consult process is completed. Reasons can vary and may include patient preference, changes in medical status or administrative reasons.

The Performer (Target system) transmits an update to the Central System and the Requester (Source system). The Requester HCP receives an update that the eReferral has been cancelled.

If request was sent to RAC (UC-03b)

F. Patient does not require additional services (step 13).

Based on the results of the assessment, the patient does not need additional services. The RAC closes the eReferral. The RAC (Target system) transmits an update to the Central System and the Requester (Source system). The Requester HCP receives an update that the eReferral has been completed.