A strategic framework for understanding your referral network and how to guide partners-in-care along this continuum.

By Emerson M. Wickwire, PhD, ABPP, CBSM

Every day, disordered sleep causes or exacerbates problems treated in every medical office within your community: cardiology, dentistry, neurology, obstetrics/gynecology, otolaryngology, pain medicine, psychiatry, and, of course, primary care, just to name a few. The simple fact is that there is an abundance of patients with sleep complaints within a stone’s throw from your office.

So, with so many people having trouble sleeping, why isn’t there a longer line at your office door? This is, of course, partially a rhetorical question: your center volumes are influenced by many factors, some of which are outside your direct control. Sleep medicine is undergoing massive change due to technological advancements, declining reimbursements, and increased attention to measurable patient outcomes. Yet regardless of your practice setting, marketing budget, or reimbursement climate, there are concrete, cost-effective steps that you can take to increase your referral volumes. And growing your practice in this way will enable you to provide first-rate sleep health care to the many people in your area who desperately need it.

What is a referral network?

In the break following my presentation at this year’s National Sleep Foundation Sleep Health and Safety conference, I was approached by a thoughtful sleep medicine professional from New York. “How do you keep your referrals up?” he asked. “Our growth is stagnated, and I’m concerned about the impact of home sleep testing.” I asked several questions, and he confided that over the past year his single best referral source has been the cardiology department from a major, well-known New York hospital. “Which doctors?” I asked. “I’m not sure,” he said. “I’ve never met them.”

Oomph. If you remember only one thing from reading this article, let it be this: referrals are relationships. If you want to maintain long-term stability in your referral volumes, you need to know who is referring to you. Not just the names of the practices, centers, or institutions, but the people. You need to listen to them, you need to get to know them, and you need to relate to them. And most important, you need to care genuinely about their patients.

A referral network is arguably the most valuable asset of any hospital-based or independent sleep disorder center. The strength of a referral network can be computed by multiplying the number of relationships you have by the perceived value of the care you provide (SRN=N*PV). So, with this in mind, let’s take a big picture view of your referral landscape.

Your referral landscape from 10,000 feet

When it comes to sleep health, the universe of potential referral sources can be broken into five segments of sleep awareness. As a sleep leader, your job is to move partners-in-care along this continuum.

Level 1: Unaware of the importance of sleep health. The fact is that most Americans, including both health care providers and the public, remain woefully ignorant of the importance of their sleep needs or the life-threatening consequences of disturbed sleep. Multiple reports indicated that more than 80% of sleep disorders go undiagnosed and untreated; lack of awareness is the single biggest culprit. From a program development perspective, individuals in this group are the furthest removed from your referral pipeline.

Action steps:

    • Develop three questions to encourage interest in sleep, such as “Did you know that…?”
    • Volunteer for community-directed educational initiatives.
    • Partner with national sleep societies for public relations/sleep awareness campaigns.

Level 2: Aware of problem, but unaware that a solution exists. This is the fastest growing segment of both health care providers as well as the lay public. If you have had access to television, the Internet, or a newspaper in the past 5 years, sleep-related headlines have been hard to miss—sleepiness linked to man-made disasters; pilots sleeping 300 miles past the runway; associations between sleep disorders and medical complications; severe consequences of disturbed sleep in military veterans; celebrity deaths associated with sleeping troubles; risks of sleeping pills; and on and on. Thanks to this media coverage, there is clearly increasing awareness of problems that can be associated with sleep. Yet there is far less awareness regarding solutions to these sleep-related problems. Even doctors in academic medical centers are frequently unaware of alternate diagnostic pathways or treatment options including mandibular repositioning devices, or the clinical and cost effectiveness of nondrug and cognitive behavioral treatments.

Action steps:

    • Develop three “quick and dirty” case studies to highlight effectiveness of sleep treatments. Follow this formula: presentation—intervention—result.
    • Volunteer to speak: church/synagogue/mosque lecture series, senior communities, cardiovascular health or weight loss centers.
    • Ensure promotional literature and website educate potential visitors of range of diagnostic and treatment options. Demonstrate your expertise. Become an ambassador for sleep health.

Level 3: Aware of problem, but unaware that your solution exists. Partners in this category are familiar with sleep and at least occasionally refer to sleep specialists. They also may provide some sleep-related services, such as home sleep testing. However, they have not heard of your organization. If a referral has been received from these providers, it was likely due to an insurance gateway or patient request (eg, based on location).

Action steps:

    • Seek introduction from trusted third party; build relationship by asking about current challenges, and offering to help overcome them. Expect nothing in return. Give anyway.
    • Add to newsletter list. Lunch/brochure drop-offs. Invite for facility tour.
    • Seek media attention for your center. Host a special event, and promote it.

Level 4: Aware of problem, aware of your solution, actively referring some or several patients. Most of your patients come from providers in this category. These providers refer one or more patients annually, but are likely missing many other patients in need of sleep services. Or they don’t recognize anything special or different about your center.

Action steps:

    • Pick up the phone. Regularly follow up to gather quality assurance data.
    • Educate your partner-in-care. Advise of upcoming sleep CME opportunities in your area.
    • Offer to provide in-service to train referring providers and staff of signs of disordered sleep, best clinical practices, and when to refer.

Level 5: Aware of problem, aware of your solution, actively and frequently referring many patients. For most centers, a disproportionate percentage of referrals comes from a very few referral sources. Although your beds are full, the sense of security is false—it only takes an unexpected practice sale or other unpredicted event to trigger a change.

Action steps:

    • Pick up the phone and regularly follow up to gather quality assurance data.
    • Seek formal or informal endorsement for your center, as permitted by law.
    • Say thank you, and mean it.

Measuring and tracking your referral success

If you want to increase your referral volumes, you must understand current referral sources and trends. In other words, ask, “Who is referring now? Are these numbers increasing, decreasing, or staying the same?” Far too often, sleep center leaders simply don’t know the answers to these basic questions because they have no referral tracking system in place. Without this information, it will be impossible to gauge the success of any targeted outreach efforts.

A number of approaches can help track these numbers, ranging from automated software solutions to old-fashioned paper and pencil. Implement a low-hanging fruit solution that works within your organizational context. At minimum, track referral sources and trends so that you can make data-driven decisions on where to focus your outreach efforts.

Five steps to starting a referral database:

Step 1: Identify the source for every new referral to your center in the past 12 months.
Step 2: Calculate the total number of referrals per referral source.
Step 3: Categorize each referral source as low, medium, or high frequency (ie, Levels 3-5, above).
Step 4: Identify any trends or commonalities among the low, medium, and high referrers.
Step 5: Pick up the phone. Gather quick and dirty quality assurance feedback. Develop targeted outreach efforts to advance partners-in-care along the referral continuum, and track results.

Your referral network is a valuable asset—without patients, you will have no practice. Therefore, you should prioritize caring for your referral network the same way you develop your clinical expertise, leadership skills, and high-quality team. Regardless of your organizational setting, professional strengths, or personal interests, it is incumbent on you as a sleep center leader to build, nurture, and maintain the professional relationships to sustain referrals to your center. This means first and foremost that you must be aware that referrals are based on relationships, and successful relationships are based on mutual value. As a sleep provider, you have tremendous value to provide.

Just as providing top-notch patient care takes preparation, effort, and follow-through, ensuring that your referral pipeline stays full requires both initial setup and ongoing attention. Understanding different levels of awareness among potential partners-in-care will help strengthen your relationships with referring providers and ensure your center’s leadership position for years to come.

In future articles, we will consider additional concrete steps that you can take to grow your practice by solidifying your role as an ambassador for sleep health. In the meantime, rest assured that the need for sleep medicine services has never been greater. It’s an ideal time to be a sleep expert. So employ these strategies and tactics to understand your referral landscape, guide partners-in-care along the referral continuum, and track your success. SR

Wickwire’s Five Laws to Maximize Referrals

1. Thou shalt be in mind. How often do your referring providers hear from you?

2. Thou shalt be available. Does every referring provider in your database have your personal email addresses and cell phone numbers?

3. Thou shalt make referring easy. How complicated is your referral form? (If the referring provider could select BPAP or ASV, they wouldn’t need you. Make it easy. Most of our referrals are made with a single checkmark.)

4. Thou shalt present a united front. If your center were “mystery shopped,” would the telephone staff, receptionist, technologist, medical assistant, and physician answer questions in the same way?

5. Thou shalt provide quality care and deliver timely reports. Do you track patient satisfaction, and respond to patient feedback? Are your reports comprehensive, useful, and provided within 48 to 72 hours?

Emerson M. Wickwire, PhD, ABPP, CBSM, is sleep medicine program director at Pulmonary Disease and Critical Care Associates in Columbia, Md, and assistant professor, part-time, at Johns Hopkins School of Medicine. He serves on the Education Committees of the American Academy of Sleep Medicine and the National Sleep Foundation.