Overview
Initiative type
Model of Care
Status
Deliver
Published
June 2026
Summary
Enabling high-value allied health care in General Medicine by reducing low value referrals so clinicians can deliver timely, impactful care where it's needed most.
Dates: 1 January 2023 - December 2025
Implementation sites: The Prince Charles Hospital
This project was presented as a Poster at CEQ Showcase 2026 (PDF 982KB).
Aim
The aim of this project was to establish appropriate referral processes to and within allied health to support all staff working to full scope of practice and delivering high value care.
Outcomes
This project has delivered a number of positive outcomes that have supported allied health to provide high value care to patients. Positive trends have been noted with:
- The number of low value referrals received (36% decrease) and time spent managing them (44% decrease). A time saving of 49 minutes per allied health clinician per week was noted
- Prevalence of generic allied health referrals (10% of audited charts)
- Referral specificity (95% of audited charts)
- Allied health staff satisfaction (91% reporting a positive change to their work satisfaction post implementation of refined referral processes)
- Perception of allied health responsiveness to referrals (minimum 9/10 on VAS score for medical and nursing)
- Perception of allied health role understanding by medical and nursing
Background
Fragmented referral pathways can reduce efficiency, and improvements may lead to cost savings, better clinical outcomes and greater patient satisfaction1. Inappropriate referrals are common and can delay therapy for those who need it most, affecting discharge planning and hospital outcomes2. Although no clear definition of high-value referrals exists, patient involvement, timely and effective communication, data sharing and understanding of roles and responsibilities can support care continuity1. Mapping referral processes with stakeholders identifies barriers and variation3. Overuse of allied health services diverts care from patients who would benefit most4. Referrer education on allied health roles and nursing-led screening tools have been shown to improve referral quality4,5,6.
Although allied health can add value to most patients they review, ageing populations, rising chronic disease and growing demand without commensurate resources mean allied health teams can no longer respond to all blanket referrals while still delivering timely, high value care.
In 2021, TPCH allied health services conducted nominal group workshops using the DARE framework7 (Discover, Abandon, Reinvest or redesign, Evaluate and embed). Clinicians identified opportunities for de implementation and reinvestment to improve value. One of the highest ranked issues was low value, generic or inappropriate referrals preventing staff from working to full scope.
In 2023, project leads undertook further investigation through 76 surveys across medical, nursing and AH staff. Key insights included:
- 95% of allied health staff received low value, generic or inappropriate referrals.
- Allied health clinicians spent an average of 1.9 hours per week managing 5.5 inappropriate referrals.
- 88% reported these referrals negatively impacted job satisfaction.
- 50% felt devalued, unable to work to full scope or deliver high value care.
- Many felt uncomfortable querying or rejecting referrals due to perceived negative impacts on team dynamics.
- No shared understanding of terminology existed around 'MDT or AH review.'
- Referral practices varied across teams and wards.
Allied health staff time and skills were being diverted by low-value, generic or inappropriate referrals, limiting their ability to work to full scope. Generic referrals lack definition, requiring time-consuming triage, unnecessary reviews, or rejection and communication of non-acceptance. High referral volumes exceed capacity, delaying timely, high-value care. Allied health expertise is best used to enable early discharge planning, reducing length of stay and preventing adverse outcomes, rather than providing duplicative and reactive care. High volumes of low-value referrals were also negatively contributing to staff satisfaction and team dynamics.
To deepen understanding, focus groups were completed with nine medical teams (n = 19) and nursing staff (n =38). Thematic analysis confirmed that generic MDT or AH referrals are low value, while high value referrals include clear, specific reasons and are typically initiated by senior staff after reviewing patients. The project team targeted these processes in implementation through co-created solutions with the support of a champion network who expressed interest in being involved.
The project benefited from strong leadership support, comprehensive stakeholder engagement and collaboration with allied health Research Fellows. The Helix Support Program provided implementation expertise and funded dedicated time for project work, with additional offline time supported by the Executive Director to embed and evaluate changes.
Methods
The project was implemented in four phases:
1. Problem clarification and identification of enablers and barriers through stakeholder consultation (via surveys and focus groups with the multidisciplinary team).
2. Co-design of referral pathways and agreement on reinvestment priorities through stakeholder meetings and Memorandum.
3. Introduction of a re-designed care model with temporary allied health Project lead role to pilot pathways, mitigate risks, provide education, training and capacity building and evaluate outcomes.
4. Provision of feedback to stakeholders through project report and presentations to allow others to tailor, scale and spread the intervention to other programs.
Multidisciplinary team education was a large component of the implementation, but given the complexity of the issue, behavioural change techniques were required for the implementation to be successful, sustainable and translatable. There was appetite for this across the team and this supported the changes made. Themes from allied health surveys and medical and nursing focus groups were mapped to the Theoretical Domains Framework (TDF) and implementation strategies were driven by Behaviour Change Wheel techniques (regulation, education and training, environmental, modelling, persuasion, enablement, monitoring of feedback)
Strategies implemented:
- Education and feedback to Clinical Management Team (CMT) meetings and allied health discipline department meetings re new processes.
- Weekly audits - feedback to individuals not complying with process via email or in person.
- Email blasts.
- Role modelling at multidisciplinary team meetings.
- Posters in key areas stating processes and allied health roles – highlighting focus of high value care for each discipline.
- Education on refined referral processes and supporting rationale to allied health (department meetings), general medical ward nurses (at handover, inservices and ad hoc over 4 months) and medical staff (Registrar orientation, IMS journal club, resident education).
- Review and modification of screening tools including the Integrated Patient Risk Assessment in collaboration with nurse educators.
- Longer term planning:
- Ongoing education to nursing staff on medical wards.
- Ongoing education to medical staff at orientation and when rotations occur.
- Allied health clinical duties/orientation processes to general medicine updated for all disciplines.
- IMS nursing orientation booklet updated to include allied health referral information.
The REAIM8 framework was used to guide evaluation of this implementation. Given its structured approach and ability to consider both individual and organisational levels it helped understand the potential for translation and sustainability of interventions. With the multiple PDSA cycles involved in this project, the REAIM assisted in assessing how well each cycle was being implemented, adopted, and maintained over time. This project was designed to be scaled and spread to other programs and with the REAIM's emphasis on external validity, the ability to successfully replicate the outcomes in other settings is supported. Each domain of the framework was considered (reach, effectiveness, adoption, implementation, maintenance).
Discussion
This project has delivered a number of positive outcomes that support the continued operationalisation of the refined processes as business as usual. Involvement of key stakeholders for co-creation of solutions was a critical to the success of this project.
Despite improvements noted, evaluation has indicated ongoing generation of generic or non-specific referrals continue to have a negative effect on the use of allied health time and skills as well as their satisfaction. In order to sustain the established changes and improvements and continue to promote a downward trend in generation of low value referrals, it is vital for the embedded multidisciplinary team champions to continue implementation of project strategies. These include cultivation of an environment where it is expected for all staff to respectfully and robustly discuss appropriate referrals and processes, with a central focus on delivery of high value patient care.
Embedded ongoing education to the multidisciplinary team will serve as a reminder as well as updated orientation documents for AH and nursing staff and feedback of outcomes to stakeholders.
Limitations:
- Clinical outcomes of quality of life and length of stay not evaluated
- Project was implemented over two years, in clear phases with incremental changes occurring through a staged approach.
- The patient cohort is highly heterogenous and it was deemed unreasonable to infer causality or objectively attribute length of stay or quality of life changes due to the project over the timeframe.
- Staff consultation formed the consumer perspective
- The intention of the project was the generation of high quality referrals rather than quick screening for all. There was concern regarding the perception of withholding services, or refined processes leading to patients missing out on allied health intervention.
- Not practically within the scope and resources, to formally evaluate the consumer (patient) experience.
- No blinding of subjects in evaluation
- Exploratory surveys and focus groups changed perceptions and raised awareness of the issues prior to formal implementation of refined processes, therefore intentions were clear from the outset.
- Education not provided to non general medical nursing staff on outlier wards
- Pilot project contained to general medical program.
- Different cohort of staff for pre and post implementation evaluation
- Due to the complexity and timeframe required for problem exploration, solution co-creation and implementation, there was an extended time between preliminary pre-implementation measures and post-implementation measures being undertaken.
Consistent feedback has been anecdotally provided that these refined processes will provide benefits to staff and programs outside of general medicine. This project was designed as a pilot to develop a translatable concept for adaptation in other programs where similar issues have been identified with low value referrals.
References
1) Peterson, S., & Heick, J. (2023). Referral Decision-Making and Care Continuity in Physical Therapist Practice. Physical therapy 103(5).
2) Patel, M., Gardner, T.A., et al. (2023). Interventions to Reduce Inappropriate Physical Therapy Consultation in the Inpatient Setting: A Quality Improvement Initiative. Journal for Healthcare Quality: Promoting Excellence in Healthcare. 45(6): 332-338.
3) Flannery, C., Dennehy, R., et al. (2022). Enhancing referral processes within an integrated fall prevention pathway for older people: a mixed-methods study. BMJ. 12(8)
4) Probasco, J.C., Lavezza, C.A., et al. (2018). Choosing Wisely Together: Physical and Occupational Therapy Consultation for Acute Neurology Inpatients. The Neurohospitalist 8(2): 53-59.
5) Oldenburg, H., Lee, M. et al. (2020). Educating Medical Students on the Roles of Occupational and Physical Therapy. Journal of allied health 49(1): 3-7.
6) Martinez, M., Cerasale, M., et al. (2021). Defining Potential Overutilization of Physical Therapy Consults on Hospital Medicine Services. Journal of Hospital Medicine. 16(9): 553-555.
7) TPCH Allied Health Research Collaborative (2025). The DARE (Discover, Abandon, Reinvest or redesign, Evaluate and embed) Toolkit: Co-creation Draft. http://healthqld.sharepoint.com/sites/MNHHS-TPCHAHResearch/SitePages/DARE-Framework.aspx
8) Improving Public Health Relevance and Population Impact (2025). What is RE-AIM. https://re-aim.org/learn/what-is-re-aim/
Key contact
Carrie Bailey and Kate McLaughlin
Advanced Physiotherapist/Team Leader Occupational Therapy
The Prince Charles Hospital
Metro North Hospital and Health Service