A problem I face in my role is not receiving timely referrals from larger hospitals letting me know that patients are coming back to the community. Patients are often left finding their own way through a medical and supportive care system that isn't the most user-friendly. I regularly see and support patients and families who do not know who to ask for support following discharge, and therefore, struggle without any assistance at all for so long that it has created its own problems.
I was recently at an education day focused on the care of brain tumor patients, and the discussion turned to how metropolitan referrals to local community services occur. It turns out that metropolitan services don't make supportive care referrals back to the community for a few reasons.
- They feel that a referral back to the GP (local doctor) is sufficient enough.
- They don't have the time to complete numerous referral forms for many different services.
- They are not aware that positions like mine exist.
I explained that the solution is simple. Phone me. Don't bother with bits of paper or electronic referral tools or spending hours re-writing a discharge summary in order to fax it to me. Phone me, phone anyone really. Pick up the phone and call the person you feel will be able to offer the most assistance for the patient and their family post discharge. This is easy and less time consuming than writing, faxing, or emailing.
I find that people, myself included, prefer to write emails when they don't want an immediate answer or when they are uncomfortable with the idea of talking to someone. I'm getting better at cold calling people and overcoming that nervousness, but I will still write an email when I don't want to talk to someone, or if I don't require an immediate answer. Phoning is for people I know already or emergencies when I really need an answer right now.
I understand that knowing who to phone is also a problem. My role is fairly unique in Victoria, Australia, and we have to work at putting ourselves forward a bit to increase our visibility. Directories are great but they need ongoing maintenance. Personal knowledge is good too, but when the person with the knowledge leaves, so does the information. A better system is needed to ensure that every patient and family are "handed over" from the bigger hospital to one local community health professional so that the patient at no point feels lost or forgotten. I haven't yet worked out what this system is, but I know one thing: It will include phone numbers and start with a call.