Staff Experiences With Implementation of the Referral Coordination Initiative

To understand VHA staff experiences with the referral coordination initiative (RCI) following nationwide dissemination.

RCI uses a team-based approach to improve the timeliness, efficiency, and patient-centeredness of specialty care referrals, while redistributing the time-intensive triage tasks from specialist providers to nurses. To assess frontline experiences with RCI, we purposively sampled four VHA sites for qualitative interviews, ensuring variability around the use of nurses in triage and the organization of scheduling staff within three high-volume specialties: cardiology, gastroenterology, and pulmonary. From May to December 2023, we conducted semi-structured interviews with 68 VHA staff members who engaged in various aspects of referral coordination, including interviews with nurses, schedulers, specialists, and referring providers.

We asked staff about challenges and facilitators to RCI implementation and maintenance. If certain RCI elements (e.g., nurse triage) were not implemented, we asked about anticipated challenges and facilitators. We analyzed qualitative data concurrently with data collection using a rapid matrix analysis approach.

Staff expressed varying perceptions around the effects of RCI and its impacts on specialist burden and clinic staffing. We identified challenges to RCI, including (1) inconsistent staff perceptions around program goals, (2) mixed perceptions around the appropriateness of nurse triage, (3) lack of clear specialty-specific triage guidelines, and (4) limited coordination with schedulers. Key facilitators of RCI included (1) leveraging existing relationships and nurses with existing specialty-specific expertise, and (2) building relationships and clear triage guidelines with specialties.

To streamline patient-centered referrals, health systems should foster working relationships between referral management teams and specialties. While nurse-led triage can improve efficiency, concerted efforts are necessary to train nurses and develop clear triage criteria.