Hamilton Centralized Access to Rheumatology Evaluation (H-CARE): A Central Triage Model

Objectives Patients referred to rheumatology in Hamilton have faced prolonged wait times due to inefficiencies in the historic referral system, where each rheumatologist independently processed and triaged incoming referrals.[1] The objective of the Hamilton Centralized Access to Rheumatology Evaluation (H-CARE) initiative was to develop and implement a central triage (CT) system for rheumatology referrals. This system aimed to establish a data-driven framework to monitor referral flow, reduce wait times, and minimize administrative inefficiencies.

Methods H-CARE was developed using the OSCARPro EMR and launched on January 27, 2025. It is staffed by 2 part-time administrative coordinators, an Advanced Clinician Practitioner in Arthritis Care (ACPAC), and staff rheumatologists who review referrals on a rotating weekly basis. Standard operating procedures were established to standardize referral intake, urgency categorization, and assignment to appropriate physicians. H-CARE operates under a CT Quality Improvement Subcommittee comprising senior rheumatologist investigators, a rheumatology fellow primary investigator, methodologists, and CT administrators. A cross-sectional descriptive analysis was conducted for the first 6 months. Metrics analyzed included the number of referrals per week, distribution by differential diagnosis, urgency category, proportion of redirected or rejected referrals, and time required for triaging.

Results In the first 6 months, a total of 1,095 referrals were processed, with 229 direct referrals to specific providers (Table 1). The most common referral diagnoses were inflammatory arthritis (IA) (226, 21%), rheumatoid arthritis (RA) (129, 12%), osteoporosis (OP) (88, 8%), vasculitis (67, 6%), and polymyalgia rheumatica (58, 5%). IA, RA, and OP accounted for over 40% of all referrals. Wait-time distribution showed 72% of referrals were triaged and booked to be seen within 3 months, with 4.7% booked within 1 week, 6.9% within 2 weeks, and 23.5% within 1 month. With H-CARE, 100% of referrals sent to individual rheumatologist’s office were booked within the time frame recommended on triage. Additionally, 100% of referrals were acknowledged within the 14-day period mandated by the College of Physicians and Surgeons of Ontario (CPSO. A total of 60 (5.5%) referrals were rejected and 144 (13.2%) were redirected to another service such as neurology, physiatry, or pain specialists.

Conclusion H-CARE has been a successful pilot, generating valuable data to inform rheumatology service demand. All referrals were assigned to rheumatologists with availability and booking within triage-designated time frames. By centralizing referral intake, H-CARE provides a scalable foundation for innovations such as integrating ACPACs and future consideration of artificial intelligence (AI)-assisted triaging within rheumatology across the region.

References [1.] Widdifield J. CMAJ Open 2016;4:E205-12.