2025 AAHA 转诊指南

Derek Burney, DVM, PhD, DACVIM (Small Animal Internal Medicine)† Veterinary Specialists of North Texas, Fort Worth, Texas

Genesis Jones, DVM† Petfolk Veterinary & Urgent Care, Raleigh, North Carolina

Christopher Byers, DVM, DACVECC, DACVIM (Small Animal Internal Medicine), CVJ CriticalCare DVM.com, VCA MidWest Veterinary Referral & Emergency Center

Courtney Campbell, DVM, DACVS-SA Stitches Veterinary Surgery, Long Beach, California

Jason B. Coe, DVM, PhD Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada

Jordan Gagne, DVM, DABVP (Canine and Feline), DABVP (Feline) Hopkinton Animal Hospital, Hopkinton, New Hampshire

Bret A. Moore, DVM, PhD, DACVO University of Florida, Department of Small Animal Clinical Sciences, Gainesville, Florida

Gene Pavlovsky, DVM, DABVP (Canine and Feline) University of Illinois, Urbana, Illinois

Chelsea Pulter, DVM Banfield Pet Hospital, Reno, Nevada

Ashli Selke, RVT, CVT Purdue University College of Veterinary Medicine, West Lafayette, Indiana

Rae Ann Van Pelt, DVM Collaborative Care Coalition, Chicago, Illinois

†Derek Burney and Genesis Jones are the cochairs of the AAHA Referral Guidelines Task Force.

Jan Bellows, DVM, DAVDC, DABVP All Pets Dental, Weston, Florida

Susie Crockett, BS, CVPM Indianapolis, Indiana

These guidelines were prepared by a task force of experts convened by the American Animal Hospital Association. This document is intended as a guideline, not an AAHA Standard of Care. These guidelines and recommendations should not be construed as dictating an exclusive protocol, course of treatment, or procedure. Variations in practice may be warranted based on the individual patient’s needs, resources, and limitations unique to each practice setting.

Evidence-guided support for specific recommendations has been cited whenever possible and appropriate. Other recommendations are based on practical clinical experience and a consensus of expert opinion. Further research is needed to document some of these recommendations. As each case is different, veterinarians must base their decisions on the best available scientific evidence in conjunction with their knowledge and experience.

Conflict of interest statement: The authors declare no conflict of interest.

AAHA gratefully acknowledges the following individuals: Mia Cary, DVM (she/her) of Cary Consulting, task force facilitator, and Roxanne Hawn, developmental editor.

CrVT (credentialed veterinary technician [e.g., CVT, LVT, RVT, LVMT])

DV (directing veterinarian)

NAVTA (National Association of Veterinary Technicians in America)

PCT (primary care team)

SCT (specialty care team)

VCPR (veterinary-client-patient relationship)

VTS (veterinary technician specialist)

Across the many types of specialty practitioners and hospitals, the requirements for veterinary patient referrals vary from one-time consultations to long-term case oversight and management. These guidelines propose a structured and technology-based approach to optimize the referral process for patients, clients, and veterinary teams. They emphasize a family-centered health care approach that keeps the focus on patients and clients through consistent collaboration between primary and specialty care teams.

Collaboration between primary care teams and specialty care teams requires detailed and timely communication and medical records sharing. Veterinary clients also need content-rich and supportive conversations as they navigate often stressful clinical situations with their pets, including the realities of referral care costs, prognoses, and possible ongoing treatments and/or management of chronic conditions.

These guidelines establish the concepts, roles, client communication strategies, and timelines that will promote successful referral relationships. Later sections offer detailed insights into the key responsibilities for the primary and specialty care team, from the initial contact before referral, through the referral itself, and then back to primary care team oversight.

The final sections consider strategies to increase access to care using team optimization and telehealth, as well as possible obstacles in the referral process and how to address or avoid them.

With the growing availability and complexity of veterinary specialization, referral to and/or consultation with veterinary specialists is a key aspect of small animal primary care practice.

The American Veterinary Medical Association currently recognizes 22 specialty organizations and 46 types of board-certified veterinary specialists.[RI-1] The Committee of Veterinary Technician Specialties through the National Association of Veterinary Technicians in America (NAVTA) recognizes 16 specialties within the field of veterinary technology.[RI-2] Across the many types of specialty practitioners and hospitals, the requirements for veterinary patient referrals vary from one-time consultations to long-term case oversight and management.

A well-ordered and smooth referral process can increase client satisfaction, improve patient outcomes, and maintain mutually beneficial professional relationships. Although there are many excellent referral relationships already, as with most relationships, interactions between primary care teams (PCTs) and specialty care teams (SCTs) can be improved by enhanced communication, open, honest discussions, and efficient referral systems.

Given the often overwhelmingly busy and fast-paced environment of today’s veterinary profession, it is understandable that communication breakdowns may occur. Streamlining referral processes to make them as easy as possible for both PCTs and SCTs, while centering the patient’s and client’s experience, can improve overall satisfaction for all parties involved.

While acknowledging that there is not a one-size-fits-all solution among today’s diverse veterinary practices, the AAHA Referral Guidelines establish the concepts, roles, client communication strategies, and timelines that will promote successful referral relationships. Later sections offer detailed insights into the key responsibilities for the PCT and SCT, from the initial contact before referral, through the referral itself, and then back to PCT oversight.

The final sections consider strategies to increase access to care using team optimization and telehealth, as well as possible obstacles in the referral process and how to address or avoid them.

Editorial note: Counts of recognized organizations and specialties in this translation reproduce the source guideline and its cited access date (August 13, 2024); they are not presented as a newly verified current registry.

Primary Care Team (PCT)—The group of professionals within a primary care veterinary practice responsible for establishing and maintaining the veterinary-client-patient relationship (VCPR) with pet caregivers and their animals for ongoing care.

This team typically includes veterinarians, credentialed veterinary technicians (CVT, LVT, RVT, LVMT), veterinary assistants, client service representatives, and support staff who work together to provide primary services that help maintain the health and well-being of companion animals.

Specialty Care Team (SCT)—The professionals who provide specialized veterinary care to patients with complex medical conditions or who require advanced diagnostics and treatments. This team typically includes board-certified veterinary specialists in various disciplines, credentialed veterinary technicians, veterinary technician specialists (VTS), and other support staff.

Directing veterinarian (DV)—The practitioner with a current or new VCPR responsible for direct management of a patient’s health concerns. During an active referral to a veterinary specialist, the specialist takes over the role of directing veterinarian for the referred health condition, and in some cases, the whole health of the pet.

The primary care veterinarian resumes the role of directing veterinarian for the specific medical care for which the patient was referred once it is agreed the referral is complete.

In cases where the specialist is unavailable, the primary care veterinarian may need to temporarily manage the specific medical condition for which the patient was referred until the specialist can take over the case.

Referral coordinator—Veterinary professionals who provide case-specific communication with clients and between the veterinary teams for a smoother process. The SCT and the PCT may have someone designated  as a referral coordinator for the practice.

Credentialed veterinary technician (CrVT)—The general term for those who hold a degree or diploma from an accredited veterinary technology or veterinary nursing program after completing formal education and training in veterinary technology/nursing, have passed a national or state exam, and obtained certification or licensure from a recognized veterinary regulatory body. The veterinary technician credentials may include the following:

Licensed Veterinary Technician (LVT)

Registered Veterinary Technician (RVT)

Certified Veterinary Technician (CVT)

Licensed Veterinary Medical Technician (LVMT)

For more information, see the AAHA Technician Utilization Guidelines at aaha.org.

Veterinary technician specialist (VTS)—These specialists undergo additional training, education, testing, and experience beyond the requirements for veterinary technician certification. To earn the VTS credential, CrVTs demonstrate proficiency in their specialized field through examinations, case logs, and other criteria established and recognized by accrediting bodies.

The AVMA recognizes 22 veterinary specialty organizations, with a total of 46 veterinary specialties. More than 16,500 veterinarians currently hold diplomate status in one or more of these specialty organizations following postgraduate training, education, and examination requirements.

American Board of Veterinary Practitioners Shelter medicine Reptile and amphibian Exotic companion mammal Canine and feline Feline Equine Fish (provisionally recognized in March 2023) Food animal Dairy Swine health management Avian Beef cattle

American Board of Veterinary Toxicology

American College of Animal Welfare

American College of Laboratory Animal Medicine

American College of Poultry Veterinarians

American College of Theriogenologists

American College of Veterinary Anesthesia and Analgesia

American College of Veterinary Behaviorists

American College of Veterinary Clinical Pharmacology

American College of Veterinary Dermatology

American College of Veterinary Internal Medicine Cardiology Small animal internal medicine Large animal internal medicine Neurology Oncology Nutrition

American College of Veterinary Microbiologists Virology Immunology Bacteriology/Mycology Parasitology

American College of Veterinary Nephrology and Urology (provisionally recognized in March 2022)

American College of Veterinary Ophthalmologists

American College of Veterinary Pathologists Anatomic pathology Clinical pathology

American College of Veterinary Preventive Medicine Epidemiology

American College of Veterinary Radiology Radiation oncology Equine diagnostic imaging

American College of Veterinary Sports Medicine and Rehabilitation Canine Equine

American College of Veterinary Surgeons Small animal surgery Large animal surgery

American College of Zoological Medicine

American College of Veterinary Emergency and Critical Care

American Veterinary Dental College Equine dental

The Committee of Veterinary Technician Specialties (CVTS) through the National Association of Veterinary Technicians in America (NAVTA) recognizes these areas of specialty within veterinary technology:

Anesthesia and analgesia

Clinical practice Exotic companion animal Production medicine Small animal (canine and feline) Small animal (feline)

Dental

Dermatology

Diagnostic imaging

Emergency and critical care

Equine

Internal medicine Cardiology Large animal Neurology Oncology Small animal

Laboratory animal Anesthetist Research Research clinical nursing (traditional or non-traditional) Surgery

Ophthalmology

Physical rehabilitation

Surgical

Veterinary behavior

Veterinary clinical pathology

Veterinary nutrition

Zoological medicine

[RI-1] American Veterinary Medical Association. Veterinary specialties. Available at: https://www.avma.org/education/veterinary-specialties. Accessed August 13, 2024.

[RI-2] National Association of Veterinary Technicians in America. The NAVTA Committee on Veterinary Technician Specialties. 2024. Available at: https://navta.net/veterinary-technician-specialties/#:~:text=The%20Committee%20on%20Veterinary%20Technicians,formation%20of%20a%20specialty%20organization. Accessed August 13, 2024.

There are three types of referral collaborations: general collaborative conversations, professional-to-professional consultations, and hands-on referrals.

By adhering to collaborative care and family-centered practice, veterinary teams can keep the patient and client at the center of the referral process.

Family-centered veterinary practitioners recognize that client and pet well-being are interconnected and aim to provide comprehensive, coordinated care.

When referring a patient for specialized care, the PCT and SCT can work together to make the process as smooth as possible for the pet and client. By adhering to collaborative care and family centered practice concepts, veterinary teams can keep the patient and client at the center of the referral process to ensure the care received supports the physical and emotional well-being of pets and their caregivers.

Collaborative care (Figure 1.1) means sharing care for a patient and client between veterinary professionals across different institutions and organizations. The combined efforts of primary care and specialty practitioners and their teams bring comprehensive diagnostic and treatment options to some instances. Depending on the type of case or the client’s location, primary care practitioners can choose from several types of veterinary referral collaborations, including telehealth consultations (Table 1.1).

PCT, primary care team; SCT, specialty care team; VCPR, veterinary-client-patient relationship

Many clients embrace referral to a SCT because they take comfort in receiving specialist-directed veterinary care for their pet. The Collaborative Care Coalition published three retrospective studies documenting the importance of collaboration for pet health and client satisfaction with referrals. Findings included increased survival times, improved quality of life for pets, and improved client perceptions when offered early referral for their pets’ conditions.

In a 2023 study, dogs receiving a diagnosis of congestive heart failure due to myxomatous mitral valve disease experienced increased survival times when treated collaboratively by a cardiologist versus by the PCT alone. Median survival time increased from 146 days to 254 days. The PCT also experienced a revenue boost owing to the increased life span of the pets.[R1-1]

A 2021 study showed dogs experienced longer intervals between bouts of otitis when treated collaboratively with a dermatologist versus when managed by the PCT alone (171 days versus 21 days).

Proliferative changes in the ear canals improved in 91% of patients, resulting in improved quality of life.[R1-2] This same study also measured client frustration, showing clients would not return to their PCT after three visits or $925 if they did not see significant improvement in their pet’s condition.[R1-3]

A third study suggested clients perceived an early referral as good value for the cost regardless of a pet caregiver’s financial situation. In the study, 70% of clients across all income brackets agreed that referral resulted in a good outcome, and client perceptions of the PCT were six times more likely to improve after referral. The study also indicated that clients valued the PCT’s involvement and willingness to work with other veterinary professionals.[R1-4]

Editorial note: The source narrative says “a 2023 study,” while its cited reference [R1-1] is dated 2016. Both dates are retained as printed; this source inconsistency has not been silently resolved.

Family-centered practice (Figure 1.2) refers to an approach to health care that focuses on pet caregivers, their pets, and the entire family. Family-centered veterinary practitioners recognize that clients and pets exist in an interconnected system that includes other family members, environmental influences, and other circumstances (e.g., socioeconomic). Practitioners who embrace this approach aim to provide comprehensive, coordinated care that meets the diverse health needs of all family members.

By treating the family, practitioners seek to promote overall well-being and improve health outcomes. This approach encompasses decisions that may include more people and nonmedical considerations. Family-centered health care means recognizing and respecting the bond between pets and clients, involving them in decision-making, and addressing emotional and practical needs concerning treatment.[R1-5],[R1-6]

Access to care refers to the availability and affordability of veterinary services. It encompasses geographic location, financial constraints, and cultural beliefs that may affect a client’s ability to obtain veterinary care.[R1-7] Enhancing access to care involves incorporating family-centered care principles and addressing the client’s concerns about referral to a veterinary specialist, the complexity of the disease and its treatment, the emotional strain of a pet’s illness, and the cost of care.

These factors may contribute to hesitation or reluctance to pursue specialized care.[R1-8]

The SCT is encouraged to embrace family-centered care during referral consultations because the client likely has no previously established relationship with the specialty practice. By engaging with the client compassionately and collaboratively, the SCT can alleviate anxiety, clarify treatment options, and empower clients to make informed decisions.

See the AAHA Community Care Guidelines for Small Animal Practice at aaha.org/community-care for more information about family-centered veterinary practice.

[R1-1] Lefbom BK, Peckens NK. Impact of collaborative care on survival time for dogs with congestive heart failure and revenue for the attending primary care veterinarian. J Am VetMed Assoc 2016;249(1):72–6.

[R1-2] Logas D, Maxwell EA. Collaborative care improves treatment outcomes for dogs with chronic otitis externa: a Collaborative Care Coalition study. J Anim Hosp Assoc 2021;57(5).

[R1-3] Logas D, Maxwell EA. Collaborative care improves treatment outcomes for dogs with chronic otitis externa: a Collaborative Care Coalition study. J Anim Hosp Assoc 2021;57(5).

[R1-4] Morello SL, Maxwell EA, Ness K, et al. Client perceptions improve with collaborative care when managing dogs with cancer: a Collaborative Care Coalition study. J Am Vet Med Assoc 2023;261(7):1037–44.

[R1-5] Williams D, Jewell J. Family-centered veterinary medicine: learning from human paediatric care. Vet Rec 2012;170(3):79–80.

[R1-6] Küper AM, Merle R. Being nice is not enough – exploring relationship-centered veterinary care with structural equation modeling. A quantitative study on German pet owners’ perception. Front Vet Sci 2019;6:56.

[R1-7] Pasteur K, Diana A, Yatcilla JK, et al. Access to veterinary care: evaluating working definitions, barriers, and implications for animal welfare. Front Vet Sci 2014;11:1335410.

[R1-8] Stoewen DL, Coe JB, MacMartin C, et al. Identification of illness uncertainty in veterinary oncology: implications for service. Front Vet Sci 2019;6:147.

Editorial note: The source webpage dates reference [R1-7] to 2014. The Crossref record for the same title, volume 11 and article 1335410 gives 2024 (DOI: 10.3389/fvets.2024.1335410). The source reference is retained and the discrepancy is disclosed here.

The PCT communicates what to expect during the referral process, including, if known, the estimated costs, timelines, additional testing, and procedures.

The PCT discusses the client’s goals for caring for their pet, including quality-of-life measures and other points for reassessment and decision-making.

The PCT’s ongoing involvement with the client and pet during the referral is a top predictor of a client’s positive feelings toward the referral process and maintains the connection with the PCT.

A disorganized referral can add to a client’s uncertainty and worry about their pet’s illness, particularly when they lack understanding of their pet’s condition, the role of the specialist, or what will happen next. [1,2] However, many clients appreciate being offered a referral as an option for their pet and welcome an opportunity to make an informed decision on their pet’s medical care.

A well-defined referral process that clearly outlines each team’s roles and responsibilities can ease client concerns and facilitate smooth and productive collaborations (Figure 2.1).

Before making a referral, have a detailed conversation with the client to ensure success. Discuss the pet’s needs, how the referral addresses those needs, and outline potential treatment goals. It is crucial to explain the likely care costs to avoid financial surprises and ensure clients are prepared for the commitment. This conversation can prevent clients from discontinuing care because of financial constraints, a common referral issue.

To avoid guesswork, SCTs should provide PCTs with estimated costs for common conditions and treatments. A qualified team member, such as a veterinary technician, can effectively handle these discussions.

Discuss the client’s goals of care for their pet: quality of life measures; points for reassessment; decision-making processes; and at-home factors, e.g., medical conditions or transportation and mobility limitations that may pose challenges with patient care.

Mitigate client concerns and trust issues. Acknowledge illness uncertainty (see below).

Explore client information needs and questions. Ask clients to share any previous experience at a specialty hospital. Address any concerns the client might have about veterinary specialists. Ensure they feel comfortable with the referral.

Personalize education on specialty care to the client and their family situation.

Manage client expectations. Warn clients there may be wait times. Work with them to mitigate the effects of the wait time. If indicated, consult with the specialist before the appointment to ensure client and patient needs are being met.

Designate a team member to serve as a referral coordinator. This team member will: provide clear communication on what to expect when going through the referral process, including estimated costs, additional testing, and procedures; describe alternative options including the potential benefits and risks; explain the process for making a referral appointment, including whether client is to contact the SCT, or if the SCT will contact the client.

Reassure the client. Stay up to date with the diagnostics and treatment plan performed by the SCT. Keep connected and engaged in the process to show clients the PCT cares about them and their pet. This can be a top predictor of a client’s positive feelings during a referral.

Illness uncertainty can occur when a client receives a diagnosis or suspected diagnosis of serious illness in their pet. It is an emotional and mental state in which the client may feel unable to make sense of the illness or be able to anticipate what the outcome of the illness will be. [3] This uncertainty can come with a sense of loss of control, cognitive stress, and an ongoing state of doubt. [4]

How does the veterinary team know if someone is experiencing illness uncertainty? In human medicine, illness uncertainty has been recognized as a central feature in the experience of illness for decades. It is, therefore, not surprising individuals would experience this state when receiving an illness diagnosis for a pet. Four factors feed into uncertainty: ambiguity about the state of the illness; unpredictability about prognosis and progression; lack of information; lack of clarity about what information exists.

Clients experiencing illness uncertainty may exhibit coping strategies such as information seeking (e.g., internet searches, online discussion groups, etc.), increased monitoring of the pet, social support, focusing on the positive, and living in the moment.

Clients may also express “denial, avoidance, selective ignoring, minimizing, selective misinterpretation, and wishful thinking.” [5] Understanding how and why these behaviors occur because of illness uncertainty can help veterinary teams better communicate with and support clients during the referral process.

Supporting clients through illness uncertainty can improve client and pet well-being and facilitate their ability to manage uncertainty. While investigations into illness uncertainty in veterinary clients are lacking, a 2019 study of veterinary oncology referrals proposed strategies to support clients experiencing illness uncertainty. [6]

1. Provide quality and structure to the information given. Too much and overly complex information can increase uncertainty and cause information overload. Give logically ordered information in digestible increments according to the client’s preferred communication methods. Adopt a staged approach (“chunking and checking”) by giving small amounts of information and then asking questions/assessing client understanding.

2. Support informed decision-making. Provide information so clients can weigh the risks/benefits of choices for care. Clients may need time to think about the initial session, so provide opportunities for follow-up conversations.

3. Prepare clients for what to expect at the referral service.

4. Support clients who are seeking information. Some pet caregivers may use the internet to find more information. Acknowledge their desire to be proactive in their pet’s care and direct them to websites and resources that offer accurate and high-quality information. Provide resources such as social and peer support groups. Validate and encourage information seeking and sharing.

5. Provide ongoing support. If possible, provide a consistent care team. Reassure the client that the PCT will continue to assist them with any questions or concerns that arise. Understand that uncertainty may change over time and encourage positive coping strategies, such as focusing on what can be controlled, remaining in the moment, and connecting with support systems.

The PCT and SCT share responsibility for a successful referral process, including decisions on preferred communication methods and streamlining processes for record sharing.

The SCT/PCT should make a specific referral roadmap available and accessible to all parties, including clients.

The PCT should always discuss the reasons for referral, cost estimates (if known), and the referral process with the client.

Reason for referral

Timing and urgency of referral

Scope of referral (e.g., referral to a board-certified veterinary dentist to treat a fractured tooth that may need to address other diseased teeth)

Preferred communication frequency and methods

Instructions for referral (provided by SCT)

Medical records, diagnostic imaging, and other pertinent details (provided by PCT)

Diagnostic and/or preoperative testing to be done before the referral (e.g., expected/preferred diagnostics before the client’s referral appointment can be listed on the SCT’s website and/or referral portal)

Consider cost-effective strategies (i.e., avoid repeat testing whenever possible)

Open communication between teams and clients remains vital throughout the referral process. Suggested communication strategies from the PCT to the SCT include:

Deliver the referral form, medical records, diagnostic test results, and diagnostic imaging by a previously agreed-upon method. Remain open to different communication strategies between teams, including email, text, fax, phone, web, or online portal.

SCTs can help facilitate these conversations by posting fees when possible or otherwise making their prices available to PCTs.

Use technology such as an online portal, if available, to complete the referral process efficiently as well as a place to upload relevant medical history.

If appropriate for the case, consider teleconsulting between the PCT and SCT with appropriate fees applied.

PCTs take responsibility for providing comprehensive medical records to the SCT, such as all reports and diagnostic images, including but not limited to radiographs, ultrasonography, computed tomography, and MRI images. To streamline this process, referral hospitals can adopt web-based submission forms. These forms provide a structured framework, facilitating clear communication between PCTs and SCTs by outlining the necessary information required for referrals and enabling seamless transmission of patient records.

Discuss the referral process with the client, including referral care cost estimates, as much as possible. In many instances (e.g., internal medicine, dentistry, surgery cases), the PCT may not be able to provide accurate estimates prior to the SCT’s assessment. However, standardizing conversations about cost and providing at least the referral fee and any other expected tests/procedures will help clients deal with the potential stress of learning about referral costs.

Referral processes differ widely across specialty practices. Standardizing the referral process is crucial because SCTs receive referrals from multiple PCTs and often see first-time clients. For instance, it may be beneficial to require that the PCT, rather than the prospective client, initiate the referral and submit the necessary documentation before the SCT reaches out to the client to schedule a consultation.

Effective and timely communication on the part of the SCT before referral enhances the experience for all involved. SCT-to-PCT communication strategies include:

A hospital webpage that clearly identifies the following information: Contact information for clients and PCTs Operating hours Directions Access to an online referral portal or other means of acquiring referral forms and providing medical records List of specialty services provided Photos and biographies of the SCT, if desired

Online referral portal with pertinent information such as: Regularly updated list of commonly performed services and procedures Detailed cost estimates on the most performed procedures and services, including consultation fees, imaging, laboratory testing, etc., for use in discussions with clients Referral roadmap

The SCT conducts a thorough review of the PCT’s provided medical records to avoid unnecessary duplication of diagnostic testing. Before arrival at the appointment, the SCT bears responsibility for fully informing clients about the necessary preparations for their pet. This includes understanding requirements such as fasting, administration of medications on the day of admission to the specialty practice, and the anticipated duration of their visit.

Moreover, the SCT must educate clients on what items to bring to the appointment, particularly medications and supplements, to verify dosages and medication instructions as evidenced by the prescription label. Additionally, the SCT may advise clients to bring a 2- to 3-day supply of any special diet prescribed for their pet in anticipation of potential diagnostic procedures, medical or surgical interventions, or hospitalization.

The PCT manages the patient until seen by the SCT.

An online referral portal facilitates communication by uploading diagnostic test results as they come in.

In urgent situations, expedited communication is imperative. Prioritize direct phone communication between the SCT and PCT over email in such cases.

“During Referral” denotes the period when the SCT assumes the role of DV regarding the specific condition for which the PCT referred the patient. The referral period continues for as long as the SCT remains the DV and may last for one or multiple visits.

Manage care until the patient can be seen When the SCT’s schedule precludes seeing the patient within the timeframe deemed optimal by the PCT, the PCT should initiate communication with the SCT promptly, either electronically or via telephone. This facilitates discussion regarding the patient’s condition and aids in determining the most appropriate interim management strategies until the SCT can see the patient.

Keep lines of communication open Once referral care gets underway, clients often feel concerned about what may or may not be happening with the SCT and contact the PCT for clarification. The PCT should communicate these questions or concerns to the SCT. This gives the SCT the opportunity to address client issues in a timely manner that is aligned with patient care goals.

Upon initiating each referral relationship, the SCT should ascertain the preferred mode of communication, i.e., whether to use the referring doctor’s direct email, the hospital’s general email, or both. When in doubt or unclear, it is always appropriate to use the hospital’s general email address.

These guidelines strongly encourage SCTs to use or develop a dedicated web-based portal to improve referral case communication and medical records sharing. (See Figure 4.1 for an example.)[R4-1] Through the portal, the SCT updates the PCT on the patient’s status with anticipated or completed diagnostics and treatment, including hospitalization. The SCT can also notify the PCT of patient discharge and plans for follow-up care.

Sometimes, situations arise that require immediate notification beyond the capability of a web-based portal, such as the death or euthanasia of a patient. In these cases, the PCT or SCT should be informed immediately via telephone or electronic means (email, messaging, etc.).

Failure to inform either the PCT or SCT of such events promptly could result in a team member contacting a client, only to discover the patient has died or been euthanized at the SCT or PCT facility without the other hospital’s knowledge. This type of miscommunication can harm a client’s trust in the PCT and/or SCT.

An easily accessible and routinely updated document, the referral roadmap provides information on how the specialty practice expects the referral process to unfold. The referral roadmap shares crucial information on the steps of the process, outlines expectations for both teams and clients, reduces uncertainty, and enhances communication.

Specialty practices can distribute the roadmap to their referring practice population by mail or digitally and make it available on the specialty hospital website and/or through the referral portal. Giving clients access to the roadmap via various client-facing channels (e.g., social media, website) can improve overall communication and expectation setting. The roadmap should be periodically updated and redistributed as needed.

The referral roadmap contains the following information:

How to initiate a referral

Standardized referral form

Information needed to submit a referral (e.g., medical records, diagnostic test results, time requirements)

Instructions on submission of documents such as images and lab results

Approximate timeline for the referral process

Frequency and method of communication updates

Options for the PCT to communicate with the SCT during the referral process

[R4-1] American College of Veterinary Surgeons. ACVS collaborative relationship communication tool. July 28, 2023. Available at: https://www.acvs.org/resources/acvs-collaborative-relationship-communication-tool/. Accessed April 4, 2024.

Re-establish the PCT relationship with the client by reviewing the referral records and discharge notes and initiating a follow-up discussion.

Establish a clear plan for continued patient and client care, including delegation of responsibilities, expectations for continued collaboration between PCT and SCT, and client contact.

Practices may assign a designated team member or referral coordinator to the case to ensure timely ongoing follow-up.

During this time, direct care for the specific health concern for which the patient was referred is transferred from the SCT back to the PCT. Communication often falters after a referral, but continued interaction between PCTs and SCTs is key to long-term patient care and client satisfaction. Both parties must maintain effective communication as the patient transitions back to the PCT for follow-up care.

Communication is best continued via the mechanism used during the referral for consistency, whether through a recommended web-based portal or by phone, email, text, fax, or social platform. To ensure ongoing follow-up occurs promptly, practices may assign a designated team member or referral coordinator to the case. At all times, maintain a clear understanding and consensus between the SCT and PCT of the short-term and long-term goals of the patient’s continued care plan.

Sharing information and records that include a running history, findings, assessment, diagnostics, plan, and updates with the client proves both useful and necessary to achieve this goal.

In some cases, long-term follow-up care may fall to the SCT, either based on client preference or owing to the complexity of the case. This can be decided on a case-by-case basis with discussion between the client, SCT, and PCT to determine what is best for the patient and family.

The SCT communicates to the PCT that care has been completed for the specific health concern for which the patient was referred. Upon the decision to transfer direct care back to the PCT, the SCT provides:

A clear account of what occurred during the referral (Figure 5.1)

A discharge report with the following minimum information:

Diagnosis (tentative or finalized)

Prognosis

Current patient status

Medications prescribed

Special diet prescribed

Treatments to be performed at home or at the PCT facility

Follow-up care needs, including the recommended timeframe for rechecks and which team is responsible for follow-up diagnostics and treatments

Any pending tests, the expected timeline for completion, and who will communicate those results with the client

The best method(s) for continued collaboration between the PCT and the SCT (e.g., when general collaborative communication is appropriate versus the request for an additional consultation).

Generic follow-up recommendations, such as suggesting laboratory work, should be avoided with the PCT. Instead, follow-up suggestions should be as specific as possible, such as recommending a follow-up appointment with the PCT in 2 wk for a complete blood count to monitor the correction of anemia, or for the removal of sutures or surgical staples. For pending tests, the SCT notifies both the client and PCT of the results and any changes indicated to the follow-up plan.

At the end of the referral period, the PCT re-establishes itself as the directing care team. This means supporting the treatment plan recommended by the SCT. To resume care, the PCT reviews the patient’s history from the SCT and confirms the required documentation is included. If necessary, the PCT contacts the SCT to request clarification.

The two teams should reach an agreement regarding compensation for future consultations, as the SCT should not be expected to provide indefinite help managing the case without compensation for their time and expertise. If the PCT would prefer that the SCT manage the ongoing problem or condition, it is appropriate to let the SCT know.

The PCT also re-establishes itself as the directing team for communication with the client. The PCT can connect with the client by asking open-ended questions regarding the patient’s mentation and behavior since their most recent visit, medication administration, and any concerns they have related to the treatment plan. Such essential discussions facilitate patient care and ensure clients follow through with treatment and follow-up plans.

Listening to the client’s feedback regarding the care experience under the SCT is an essential aspect of the referral process. The PCT can share these client assessments with the SCT as relevant, including considerations regarding family-centric decisions, positive feedback, constructive feedback, and any concerns with the plan moving forward.

The PCT’s communication with the client includes details about future examinations, diagnostic results, and modifications to the treatment plan. The PCT also takes responsibility for scheduling follow-up examinations, laboratory work, or other diagnostics as necessary to successfully continue the patient’s care as recommended by the SCT’s treatment plan. Some patients require multiple visits or direct follow-up with the SCT, so clearly delineate these details in the treatment plan.

A designated PCT member can communicate relevant or time-sensitive updates to the client. Schedule team members accordingly to allow enough time for these discussions with the client via phone, email, or virtual platform.

Team optimization relies on frequent, timely, and accurate intrateam and interteam contact that focuses on problem-solving to support an efficient and effective referral process from beginning to end.

The well-being of team members directly impacts the overall functioning and effectiveness of a veterinary team, making it critically important that the referral process embraces a healthy working partnership between the PCT and SCT.

Empowering key roles within the referral process on both the PCT and SCT maximizes the outcomes for clients, patients, and the veterinary team.

Team optimization reflects the most effective use of time, resources, and personnel throughout the referral process within the PCT, within the SCT, and at both teams’ interface. Optimization also means understanding the different roles that members of the veterinary care team (e.g., CrVT, VTS) can play to free up the veterinarian for other tasks.

Providing team members with autonomy, resources, support, and encouragement to optimize their role within the referral process fosters team engagement and efficiency and improves outcomes for patients, clients, and both teams.

Map the referral process to identify key roles (e.g., CrVT, VTS, client service representative, referring veterinarian, referral coordinator) and role interdependencies requiring coordination to support the referral process within the PCT.

Provide the necessary training for staff within identified roles, including education on the referral process, appointment scheduling, referral form completion, and submission of supplementary medical information (e.g., medical records, diagnostics).

Continually evaluate and refine the internal referral process by soliciting client and team feedback and making changes as required.

Research and stay current on referral processes from various specialty practices used by the hospital to ensure the PCT’s referral process is modified as needed.

Stay informed about which specialty hospitals have the means for specific diagnostic tests or offer certain specialties. PCTs can keep a “preferred” list of specialty practices and their capabilities for quick reference.

Identify a dedicated referral coordinator (often a CrVT or VTS) and map the referral process to identify additional roles and role interdependencies requiring coordination to support an efficient and successful referral within the SCT.

Provide targeted training to ensure team members gain the skills and resources needed to facilitate the referral process within the SCT, including communication and project management skills.

Establish appointment intake processes to facilitate prompt and accurate scheduling of the correct specialist’s appointments and ensure all necessary referral information is accessible to the appropriate SCT.

Streamline procedures and processes specific to each specialty by regularly evaluating and refining each specialist’s workflow to ensure seamless referral handling from initiation to completion by their respective SCT.

Conduct a collaborative review and refinement of the referral process. Members from both the PCT and SCT can comprehensively assess the effectiveness of the referral process.[R6-1] This may require the expertise of the referral coordinator or another designated team member to conduct ad hoc surveys and gather feedback from all parties.

Gather and share client feedback. It is important that the PCT share any feedback received with the SCT, especially if it identifies needed improvements in the process.

Share best practices during joint meetings and/or continuing education opportunities. Address challenges, brainstorm innovative solutions, and foster relationships between the PCT and SCT to optimize the referral experience for patients and clients.

Creating a supportive and healthy referral environment based on mutual respect and understanding requires equipping teams to navigate challenging situations effectively while promoting appropriate self-care.

Provide communication training to support collaborative relationships, reduce miscommunication, proactively resolve conflict, and promote psychological safety.

Promote a positive referral culture based on mutual respect and understanding by focusing on problem-solving versus assigning blame when issues arise.[R6-2]

Provide accessible resources for self-help and self-care to support the well-being of individual team members as needed. Options include designating PCT and SCT point persons to resolve intrateam or interteam conflicts, provide access to mental health support services, and offer team members opportunities for well-being–related continuing education and professional development.

Recognizing and empowering members of the PCT and SCT is vital for optimizing the referral process and supporting job satisfaction and well-being.[R6-3],[R6-4]

Provide autonomy and ongoing support for team members to operate within their roles and scope of practice. This encourages initiative and problem-solving and assists by freeing up other team personnel and resources.

Offer continuing education and professional development opportunities at the individual and team levels to enhance professional efficacy and strengthen the referral process.[R6-5] These opportunities can also be used to exchange updated information regarding referral to specialty care.

For more information on team optimization, see the AAHA Technician Utilization Guidelines and the AAHA Mentoring Guidelines at aaha.org.

[R6-1] Best C, Coe JB, Hewson J, Meehan M, Kelton D, Black B. Referring equine veterinarians’ expectations of equine veterinary specialists and referral centers. J Am VetMed Assoc 2018;253:479–89.

[R6-2] Best C, Coe JB, Hewson J, Meehan M, Kelton D, Black B. Referring equine veterinarians’ expectations of equine veterinary specialists and referral centers. J Am VetMed Assoc 2018;253:479–89.

[R6-3] Moore IC, Coe JB, Adams CL, Conlon PD, Sargeant JM. The role of veterinary team effectiveness in job satisfaction and burnout in companion animal veterinary clinics. J Am Vet Med Assoc. 2014;245:513–24.

[R6-4] Pizzolon CN, Coe JB, Shaw JR. Evaluation of team effectiveness and personal empathy for associations with professional quality of life and job satisfaction in companion animal practice personnel. J Am Vet Med Assoc. 2019;254:1204–17.

[R6-5] Moore IC, Coe JB, Adams CL, Conlon PD, Sargeant JM. The role of veterinary team effectiveness in job satisfaction and burnout in companion animal veterinary clinics. J Am Vet Med Assoc. 2014;245:513–24.

Consider integrating teleconsulting routinely into practice for cases that may benefit from specialty care.

Teleconsultation can help reduce client frustration over long wait times for referral appointments by helping PCTs with case management in the interim.

Teleconsultation can offer many benefits, including timely advice, continuity of care, and expanded service offerings within the practice.

Teleconsultation (Table 7.1) involves direct communication between the PCT and SCT to discuss the specifics of a case. It allows primary care veterinarians to seek expert advice, collaborate on cases, and obtain guidance on diagnosis, treatment, and management of patients from veterinary specialists. Typically, clients pay the initial cost of teleconsulting, and follow-up teleconsultation fees can also be integrated into the fee structure.

Ultimately, teleconsulting may reduce client costs and frustration over long referral wait times. Teleconsultation can provide more information on possible differentials and approaches and offer suggestions for further testing, empirical treatment, and/or medication adjustments while waiting for the referral appointment.

Teleconsulting improves access to veterinary care, helping to ensure pets receive timely and appropriate interventions regardless of geographical limitations. In areas with limited access to specialists or if clients cannot appear in person because of physical and/or financial constraints, teleconsulting can fill the gap by helping PCTs manage cases.

By involving teleconsultants, the PCT can offer clients reassurance and confidence in the care being provided to their pets and address any hesitations pet caregivers feel about pursuing treatment and referral.

PCTs could consider integrating teleconsulting for cases that may benefit from specialty care. In situations where clients may prefer not to visit a specialist in person, teleconsultation can enhance the PCT’s ability to manage complex cases, thereby improving patient outcomes and client satisfaction.

Professional courtesy can go a long way; communicate misdiagnoses or differences in medical opinions with humility and directness.

Set client expectations that the SCT may need to repeat some diagnostic and monitoring tests.

Meticulous record-keeping helps both teams avoid unnecessary duplication of diagnostics.

Disruptions to the referral process lead to less successful patient outcomes and decreased client satisfaction, but there are some proactive strategies that can help avoid these referral pitfalls. See Table 8.1 for some of the most common disruptions and strategies to overcome them.

[R8-1] Best C, Coe JB, Hewson J, Meehan M, Kelton D, Black B. Referring equine veterinarians’ expectations of equine veterinary specialists and referral centers. J Am Vet Med Assoc. 2018;253:479-489.

[R8-2] Best C, Coe JB, Hewson J, Meehan M, Kelton D, Black B. Referring equine veterinarians’ expectations of equine veterinary specialists and referral centers. J Am Vet Med Assoc. 2018;253:479-489.

[R8-3] Best C, Coe JB, Hewson J, Meehan M, Kelton D, Black B. Referring equine veterinarians’ expectations of equine veterinary specialists and referral centers. J Am Vet Med Assoc. 2018;253:479-489.

[R8-4] Lefbom BK, Peckens NK. Impact of collaborative care on survival time for dogs with congestive heart failure and revenue for the attending primary care veterinarian. J Am Vet Med Assoc. 2016;249(1):72-6.

A well-defined referral process with a clear delineation of roles and responsibilities is fundamental to enhancing client satisfaction, strengthening relationships between primary care and specialty practices, and ultimately improving patient outcomes. These guidelines have outlined key components of a successful referral process, beginning with understanding the benefits of collaborative care and establishing a family-centered approach as the cornerstone of client communication.

By detailing the specific roles of primary care and specialty care teams throughout the referral journey, these guidelines have provided a framework for seamless patient transitions. They have also highlighted the growing importance of technology, advocating for web-based portals to streamline communication and facilitate secure medical record sharing, and the use of teleconsultations to better meet client and patient needs.

As veterinary medicine advances rapidly and offers an expanding array of treatment options, efficient referral processes become increasingly vital. Although the guidelines acknowledge that not all recommendations offered here will work with all practices, it is hoped that by implementing these guidelines, practices can foster stronger interprofessional relationships, ensure more comprehensive patient care, and ultimately contribute to healthier pets and happier clients.

The five numbered figures are retained as English-original links on their official chapter pages; this reader does not contain Chinese redrawings. The separate implementation toolkit is not part of this translated narrative and tables.