Table 3.

Processes of high-quality pediatric subspecialty referrals

Domain/Step	Subdomain	Definition
1. Referral decision	Shared decision making	Collaborative decision making between patients and providers
	Clear referral reason	Decision making results in clear reason for referral
	Specific subspecialist identified	Decision making results in identification of specific subspecialist for referral
2. Pre-visit information transfer	PCP records provided to subspecialist	PCP records available to subspecialist either through active transfer or shared electronic health record
	Subspecialist reviews records prior to visit	Subspecialist reviews available records prior to visit
3. Appointment scheduling	Amount of time spent scheduling appointment	Cumulative amount of time spent by family calling subspecialty office to schedule appointment, including repeat calls, time on hold, etc
	Reliability of processes for scheduling appointment	Certainty that messages left with subspecialty office will be returned in a timely manner
	Timely appointment scheduled	Ability to schedule appointment within an appropriate timeframe for the child’s medical needs
	Convenient appointment scheduled	Ability to schedule appointment that accommodates child’s non-medical needs (school, etc) as well as needs of the family (work schedule, school/daycare schedules for other children)
	Avoidance of unexpected cancellations	Appointments cancelled by subspecialist office, potentially without adequate explanation or rescheduling
4. Subspecialist Visit	Diagnosis modified	New diagnosis or refined diagnosis obtained through visit
	Treatment plan modified	New treatment plan or modified treatment plan obtained through visit
	Tasks completed	Ability to accomplish needed tasks, such as medication refills, testing/evaluation, form completion
	Developmental/transition needs addressed	Attention to child’s developmental/transition stage throughout visit
	Education/community needs addressed	Attention to child’s non-medical needs including education needs and connection with community resources
	Financial/insurance needs addressed	Attention to impact of child’s health on family finances and identification of potential resources/solutions
	Family needs addressed	Attention to impact of child’s health on family relationships and needs, and identification of potential resources
	Efficiency of registration processes	Minimization of time spent registering or completing paperwork
	Appointment occurs on time	Minimization of time spent waiting for care
	Avoidance of unnecessary visits	Avoidance of visits where the caregiver/child perceived no value
	Adequate time with subspecialist	Caregiver/patient reports adequate time with subspecialist during scheduled visit to accomplish all needed goals of visit
	Subspecialist listened, showed respect	Caregiver/patient perceives that subspecialist listened adequately and respected their contribution to the visit
	Subspecialist views patient as unique individual	Caregiver/patient perceives that subspecialist understood unique value and unique needs of their child
	Subspecialist considered comprehensive needs	Caregiver/patient perceives that subspecialist addressed comprehensive needs of their child
	Shared decision making during visit	Patient/caregiver preferences considered by subspecialist during visit
5. Post-visit information transfer	Received clear after-visit plan of action	Clear actionable summary provided by subspecialist to patient/caregiver
	Recommended to see additional subspecialists	Discussion of additional subspecialists to be seen
	Subspecialist communicated with PCP in a timely manner	Transfer of written or verbal information to PCP in a timely manner
	Subspecialist followed through as promised	Certainty that subspecialist would complete follow-up tasks as promised (i.e., follow-up phone calls, faxing prescriptions, etc)
6. Ongoing care integration and after-visit communication	Ability to contact subspecialist with questions or changes in status	Family is able to communicate with subspecialist after or between visits
	Ability to contact subspecialist in a timely manner	Family is able to hear back from subspecialist in a timely and reliable manner between visits
	Ability to schedule timely follow-up visit	Family is able to schedule follow-up appointments within the timeframe designated by subspecialist
	Ability to complete tasks between appointments	Family is able to obtain prescription refills, coordinate labwork/imaging, obtain results, etc between visits
	Comprehensive care between visits	Perception that a provider is able to address comprehensive needs between visits
	Continuous care (rather than episodic, visit-based care)	Perception that subspecialist thinks about child between visits and/or is accessible to advance care between visits
	Patient/PCP able to access subspecialist records after/between visits	Ability of patient/caregiver and PCP to view subspecialty notes, recommendations, or results
	PCP involvement with care coordination	Involvement of PCP in ongoing care coordination, appointment scheduling
	PCP and subspecialist comanagement	Clear roles and areas of care for PCP and subspecialist in ongoing care relationship
	Communication between subspecialists	Perception of adequate communication and coordination between different subspecialists
	Continuity with subspecialist	Ability to maintain continuity for follow-up visits and for communication between visits
	Respect for/trust in subspecialist	Perception of ongoing care by trusted subspecialist