skip to content

Transitions in Care

Print page icon

Approved by Council: September 2019

Companion Resource: Advice to the Profession

 

Policies of the College of Physicians and Surgeons of Ontario (the “College”) set out expectations for the professional conduct of physicians practising in Ontario. Together with the Practice Guide and relevant legislation and case law, they will be used by the College and its Committees when considering physician practice or conduct.

Within policies, the terms ‘must’ and ‘advised’ are used to articulate the College’s expectations. When ‘advised’ is used, it indicates that physicians can use reasonable discretion when applying this expectation to practice.

 

Policy

Keeping Patients Informed About Who is Involved in Their Care

  1. Within hospitals or health-care institutions where care is provided by a team of changing individuals, physicians must coordinate with others on the team to keep patients informed about who has primary responsibility for managing their care (i.e., their most responsible provider).1
  2. Referring physicians must clearly communicate to patients what the physician’s anticipated role will be in managing care during the referral process, including how patient care and follow-up may be managed and by whom, and keep patients informed about any changes that occur in their role.
  3. Consultant physicians2 must clearly communicate to patients the nature of their role, including which element(s) of care they are responsible for and the anticipated duration of care, and keep patients informed about any changes that occur in their role.
    1. When it is possible to do so, consultant physicians must also clearly communicate when the physician-patient relationship has reached its natural conclusion or when it is anticipated that it will reach its natural conclusion.3

Managing Patient Handovers in Hospitals and Health-Care Institutions

  1. When handing over primary responsibility for patients to another health-care provider, physicians must facilitate a comprehensive and up to date exchange of information and allow for discussion to occur or questions to be asked by the health-care provider assuming responsibility.4

Discharging Patients from Hospital5 to Home

  1. Prior to discharging an inpatient from hospital to home,6 physicians must ensure that they or a member of the health-care team has a discussion with the patient and/or substitute decision-maker about:
    1. Post treatment or hospitalization risks or potential complications;
    2. Signs and symptoms that need monitoring and when action is required;
    3. Whom to contact and where to go if complications arise;
    4. Instructions for managing post-discharge care, including medications (e.g., frequency, dosage, duration); and
    5. Information about any follow-up appointments or outpatient investigations that have been or are being scheduled or that they are responsible for arranging and a timeline for doing so.
  2. Physicians must take reasonable steps to facilitate the involvement of the patient’s family and/or caregivers in the discharge discussion where the patient or substitute decision-maker indicates an interest in having them involved and provides consent to share personal health information.
  3. Physicians must use their professional judgment to determine whether to support this discussion with written reference materials, and if so, the specific nature of the materials. In making these determinations, physicians must consider a variety of factors including:
    1. the health status and needs of the patient;
    2. post treatment or hospitalization risks or potential complications;
    3. the need to monitor signs or symptoms;
    4. whether follow-up care is required;
    5. language and/or communication issues that may impact comprehension;
    6. whether those involved in the discussion are experiencing stress or anxiety which may impair their ability to recall and act on the information shared; and
    7. where the patient is being discharged to.

Completing and Distributing Discharge Summaries

  1. The most responsible physician must complete a discharge summary for all inpatients within 48 hours of discharge.7
  2. The most responsible physician must include in the discharge summary the information necessary for the health-care provider(s) responsible for post-discharge care to understand the admission, the care provided, and the patient’s post discharge health care needs. While physicians must use their professional judgment to determine what information to include in the discharge summary, it will typically include:
    1. Relevant patient and physician identifying information;
    2. Reason(s) for admission;
    3. Any diagnoses or differential diagnoses at discharge;
    4. A summary of how active medical problems were managed (including major investigations, treatments, or outcomes);
    5. Medication information, including any changes to ongoing medication and the rationale for these changes;
    6. Follow-up care needs or recommendations; and
    7. Appointments that have or need to be scheduled, any relevant and outstanding outpatient investigations, tests, or consultation reports.
  3. The most responsible physician must use language that is understandable to the health-care providers who will receive the discharge summary.
  4. The most responsible physician must direct that the discharge summary be distributed to the patient’s primary care provider, if there is one, and/or another health-care provider who will be primarily responsible for post-discharge follow-up care.
  5. If a delay in the completion or distribution of the discharge summary is anticipated, the most responsible physician must provide a brief summary of the hospitalization directly to the health-care provider responsible for follow-up care in a timely manner.
  6. Where follow-up care is time-sensitive or the patient’s condition requires close monitoring, the most responsible physician must also consider whether direct communication with the health-care provider assuming responsibility for follow-up care is warranted.

Making Referrals8

  1. Referring physicians must have a mechanism in place to track referrals where urgent care is needed, in order to monitor whether referrals are being received and acknowledged.
    1. Referring physicians must engage patients in this process by, for example, informing them that they may contact the referring physician’s office if they have not heard anything within a specific time-frame.
  2. Referring physicians must make a referral request in writing and include the information necessary for the consultant health-care provider to understand the question(s) or issue(s) they are being asked to consult on. While physicians must use their professional judgment to determine what information to include in the referral request, typically this will include:
    1. Patient, referring physician, and, if different, primary care provider identifying information;
    2. Reason(s) for the consultation and any information being sought or questions being asked;
    3. The referring physician’s sense of the urgency of the consultation; and
    4. Summary of the patient’s relevant medical history, including medication information and the results of relevant tests and procedures.
  3. If the patient’s condition requires that a consultation be provided urgently, a verbal referral request may be appropriate, although the referring physician must follow-up with a written request.

Acknowledging Referrals

  1. Consultant physicians must acknowledge referrals in a timely manner, urgently if necessary, but no later than 14 days from the date of receipt.9
  2. When acknowledging the referral, consultant physicians must indicate to the referring health-care provider whether or not they are able to accept the referral.
    1. If they are, consultant physicians must provide an anticipated wait time or an appointment date and time to the referring health-care provider. When providing an anticipated wait time, consultant physicians must follow-up once an appointment has been set.
    2. If they are not, consultant physicians must communicate their reasons for declining the referral to the referring health-care provider.

Communicating Consultant Appointments with Patients

  1. Consultant physicians must communicate the anticipated wait time or the appointment date and time to the patient, unless the referring physician has indicated that they intend to do so, and must allow patients to make changes to the appointment date and time directly with them. When providing an anticipated wait time, consultant physicians must follow-up once an appointment has been set.

Preparing and Distributing Consultation Reports

  1. Following an assessment of the patient (which may take place over more than one visit), consultant physicians must prepare a consultation report that includes the information necessary for the health-care provider(s) involved in the patient’s care to understand the patient’s health status and needs. While physicians must use their professional judgment to determine what information to include, this will typically include:
    1. Relevant patient, consultant physician, and referring health-care provider identifying information;
    2. The date(s) of the consultation;
    3. The purpose of the referral;
    4. A summary of the relevant information considered, including a review of systems, physical examinations and findings, and the purpose and results of tests or investigations;
    5. A summary of the conclusions reached, including any diagnoses or differential diagnoses;
    6. Treatments initiated or recommended, along with their rationale, including medications or changes in ongoing medications;
    7. Outstanding investigations and referrals, along with their rationale;
    8. Important advice given to the patient; and
    9. Recommendations regarding follow-up and whether ongoing care from the consultant physicians is needed.
  2. When consultant physicians are involved in the provision of ongoing care, they must prepare follow-up consultation reports when there are new finding or changes are made to the patient’s care management plan. While physicians must use their professional judgment to determine what information to include, this will typically include:
    1. The original problem and any response to treatment;
    2. Subsequent physical examinations and their findings;
    3. The purpose and results of additional tests or investigations; and
    4. Conclusions, recommendations, and follow-up plan(s).
  3. Consultant physicians must distribute consultation reports to the referring health-care provider and, if different, the patient’s primary care provider.
  4. Consultant physicians must distribute the consultation report and any subsequent follow-up reports in a timely manner, urgently if necessary, but no later than 30 days after an assessment or a new finding or change in the patient’s care management plan. What is timely will depend on the nature of the patient’s condition and any risk to the patient if there is a delay in sharing the report.
    1. If urgent, a verbal report may be appropriate, although the consultant physician must follow-up with a written consultation report.

Record Keeping of Referral Requests and Consultation Reports

  1. Both referring and consultant physicians must keep a copy of the referral request and any consultation reports in their respective patient medical records. Where the referring and consultant physician have access to a common medical record, referral requests and consultation report may be contained in that common medical record.

Using Technology to Prepare and Distribute Referral Requests and Consultation Reports

  1. Physicians who use technology to assist in the preparation and distribution of referral requests or consultation reports must ensure that they are accurate and follow-up with the receiving health-care provider if any errors are identified after the referral or consultation report has been sent.
 

Endnotes

1. Recognizing that the scopes of practice of other health-care providers are evolving and that other health-care providers may have overall responsibility for managing patient care, this section of the policy has adopted the term “most responsible provider” as opposed to “most responsible physician” (see the Canadian Medical Protective Association’s “The most responsible physician: a key link in the coordination of care” for more information).

2. This policy uses the term “consultant physician” in order to capture any physician, including primary care physicians, who accept referrals.

3. See as well the College’s Ending the Physician-Patient Relationship policy.

4. The information may be exchanged through a variety of methods including: in person, via e-communication, or static communication methods such as a patient information board within a hospital department. Similarly, any discussion that is required can be done in-person, or through the phone, text, or other methods of e-communication, so long as doing so is in compliance with physicians’ obligations under Personal Health Information Protection Act, 2004 S.O. 2004, c. 3 Sched. A. (hereinafter, PHIPA).

5. This includes people who have been admitted as inpatients to any type of hospital, including complex continuing care facilities and rehabilitation hospitals

6. Home is broadly defined as a person’s usual place of residence and can include, for example, institutions such as a retirement home or long-term care.

7. Physicians are reminded that they must complete the discharge summary within 48 hours of discharge in order to bill the Ontario Health Insurance Plan for a patient visit on the day of discharge.

8. The expectations set out in this policy apply broadly to all referrals with the exception of effective referrals that are made when physicians choose to limit the services they provide for reasons of conscience or religion. Specific expectations for effective referrals are set out in the College’s Professional Obligations and Human Rights and Medical Assistance in Dying policies.

9. The date of receipt would be the first day of practice for physicians returning from vacations or other temporary absences from practice (as defined in the Availability and Coverage policy).