Continuity of care

The CPSO has acknowledged the challenges currently faced by the medical profession:

• All physicians are facing significant challenges as clinical and administrative workload increases and as pressure on the health system continues to rise. It is more important than ever that physicians work together to deliver quality care to Ontario patients

Ordering tests and tracking results for referred patients

The CPSO has added direction around who is responsible for ordering tests and tracking results for referred patients:

• Generally, any physician who determines that a test is needed is responsible for ordering that test, tracking the results and managing any follow-up stemming from that test
• In some instances, however, a specialist may recommend that the family physician or another specialist arrange testing. For example, if during the course of an assessment, a specialist makes an incidental finding unrelated to the consultation (including abnormal lab or imaging tests) that is not urgent and not typically within the scope of the specialist to investigate or manage, they need to inform the patient of the finding and advise the patient to follow-up with their family physician
• However, if the result of a test ordered by a specialist yields an incidental finding that needs to be urgently managed, the specialist needs to communicate the results to the patient and take steps to arrange timely follow-up for the patient
• In general, physicians in the patient’s circle of care may be able to accept responsibility (i.e., tracking and/or follow-up) for a test ordered by another physician, but the receiving physician has to agree to accept responsibility for the test

Ordering tests recommended by another physician via e-consult

Physicians who provide e-consult services may not assess patients directly but might recommend that a test be ordered. In these cases, the physician seeking advice from the e-consultant physician would order the test and follow-up on the results.

Ordering non-urgent tests recommended as a result of urgent or emergent episodic care

In some situations, physicians might provide urgent or emergent episodic care, such as in an emergency department. Any recommendations for additional non-urgent investigations that fall outside of the acute care being provided are not generally the responsibility of the physician providing the urgent or emergent care.

Copying the patient’s primary care provider on test requisitions

The CPSO continues to advise that it is generally good practice to copy the patient’s primary care provider on test requisition forms. They have added direction around the primary care provider’s responsibilities.

• It is generally good practice to copy the patient’s primary care provider on a test requisition so they are aware of the tests ordered and the results; however, they would have no additional responsibilities in regard to the tests or results, unless there is reason to believe that a clinically significant test result has not been followed-up on

In the context of referrals, the CPSO has affirmed the following:

• Referring physicians and consultant physicians share responsibility for ensuring patients can access the care they need

Making referrals

The CPSO has added the following statements on making referrals:

• Referring physicians will need to have conducted an appropriate assessment before referring a patient to a consultant physician
• If a patient requires urgent care, it may be appropriate for referring physicians to speak directly with consultant physicians to ensure the patient can be seen as soon as possible. However, any verbal consultation request must be followed up with a written request from the referring physician

Making referrals to a sub-specialist

The CPSO has added direction on who is responsible for referring patients to a sub-specialist:

• In most cases, the consultant physician rather than the referring physician is responsible for making the referral if they determine after an assessment that subspecialist care is needed
• If a consultant declines a referral on the basis that a sub-specialist is needed, the referring physician would be responsible for initiating another referral to an appropriate sub-specialist

Making virtual care re-referrals

The CPSO has reminded physicians that changes to virtual care billing came into effect in December 2022, which means that consultant physicians who provide virtual care will need to preserve their physician-patient relationships to bill for the comprehensive care they provide. As a result, referring physicians may need to reissue straightforward referrals every 24 months where ongoing virtual care is needed.

• Referring physicians may need to reissue straightforward referrals every 24 months where ongoing virtual care is needed. While physicians must determine what information to include in these referrals, they can be straightforward and meet the expectations set out in the Transitions in Care policy if they include the patient’s name, the referring physician’s name, and a statement indicating that the patient should continue to receive comprehensive virtual care from the consultant physician, along with any changes in the patient’s condition

Receiving, acknowledging and accepting/declining referrals

Regarding the requirement to acknowledge referrals within 14 days of receipt, the CPSO has clarified:

• Acknowledging a referral simply means informing the referring physician whether the referral will be accepted. If it is accepted, consultant physicians can indicate the estimated or actual appointment date. There is no requirement to see the patient within 14 days, just a requirement to review the referral and close the loop

The CPSO has added the following statements on accepting and declining referrals:

• Consultant physicians can support referring physicians by accepting consultation requests, where possible, even if there are minor issues with the requests (e.g., incorrect or outdated referral forms)
• It is important that consultant physicians who use e-referral platforms also provide an alternative option for physicians who are unable to access this platform. This will allow referring physicians to complete their consultation requests in a timely manner and will help ensure patient care is not unnecessarily delayed
• Consultant physicians can decline referrals that do not provide sufficient information, but they must communicate their reasons to the referring physician. Rather than having the referring physician make a new referral, there may be opportunities for the consultant physician to work with the referring physician to clarify any outstanding questions

Regarding whether consultant physicians have any obligation to suggest another provider if they’re unable to take on the referral, the CPSO has clarified:

• Consultant physicians may have more information about their colleagues than referring physicians do. If they are able to assist the referring physician in re-directing the referral, it would be helpful to do so, especially where the referral is for urgent or unique issues

Issuing consultation reports

The CPSO has added direction on how consultation reports can support referring physicians:

• It is important for consultation reports to be clear and include a summary of the information necessary for the referring physician to understand the patient’s needs and follow-up care. Depending on the circumstances, they may be short, or they may require more comprehensive and detailed notes

Providing follow-up care

The CPSO has clarified responsibilities with respect to follow-up care:

• Consultant physicians will need to provide appropriate follow-up care and handle any administrative work stemming from this care. Referring physicians may not have the expertise or resources needed to manage a patient’s specialised care

Issuing discharge summaries

The CPSO has clarified expectations around the timing of hospital discharge summaries:

• The policy does not require that the discharge summary be transcribed and distributed within 48 hours. Rather, the policy requires the most responsible physician to complete their component of the discharge summary within 48 hours of discharge (for example, completing dictation). While the policy requires that this be done within 48 hours of discharge, it’s considered best practice for physicians to complete their dictation at the time of discharge as doing so will contribute to the timely completion and distribution of the discharge summary.