Referrals and the PCMH: how well do we know our neighborhood?

Characterize patterns of referral from a patient-centered medical home (PCMH) and observe the association of provider experience, patient chronic disease burden, and risk of utilization on referral placement.

Descriptive analysis of referral patterns in an academic, internal medicine PCMH.

We examined referrals (eg, specialist visit, testing, ancillary services) placed between July and December of 2014 in an academic PCMH caring for a total of 12,000 patients. All referrals originated from the outpatient PCMH clinic and were divided into resident or faculty clinic based on the assigned primary care provider. Patients with a referral during the 6-month study period served as the unit of analysis, and we developed a generalized linear model to identify variables associated with referral placement. We estimated the association of the patients' risk of healthcare utilization using a risk stratification tool.

The faculty placed 1709 referrals for 3055 unique patients seen compared with 2388 referrals for 2434 unique patients seen by residents. For those patients receiving referral, a mean of 1.72 referrals were placed, with residents having significantly more referrals per patient (1.9 ± 1.3 vs 1.5 ± 0.9; P < .0001). For patients at highest risk of utilization, residents were referred at a rate of 0.327 compared with 0.226 (P = .0035) in the faculty clinic.

In an academic setting, provider and patient factors play a role in referral patterns. Residents refer highest-risk patients more often than their faculty counterparts, while there is no difference for lower-risk patients.