Why Patient Referral & Transfer Matter for Continuity of Care

Imagine a patient with a chronic illness who has been seeing the same doctor for years. The doctor knows their full medical history, understands their concerns, and has built a relationship based on trust. This is continuity of care (CoC)—the idea that healthcare should be seamless, coordinated, and patient-centered.

For primary care providers, maintaining CoC is straightforward—they see their patients regularly and track their progress over time. But what happens when a patient needs specialized treatment at a tertiary hospital? How can CoC be preserved in a system where patients move between different levels of care? This is a major challenge for healthcare systems worldwide, and tertiary hospitals must play an active role in ensuring that care remains connected, even after a referral or transfer.

 

Continuity of Care in Primary Healthcare

In primary care settings, CoC is built through long-term relationships between doctors and patients. Primary care physicians don’t just treat illnesses—they manage overall health, prevent complications, and provide ongoing support. (A future post will discuss how primary care institutions in Korea often struggle to fulfill this role.) Their role is crucial in guiding patients through the healthcare system, especially when specialized care is required.

However, the moment a patient is referred to another facility, there’s a risk that their medical journey could become fragmented. This is why effective communication and well-structured referral systems are essential to maintaining CoC beyond primary care.

The Role of Tertiary Hospitals in Continuity of Care

Tertiary hospitals are highly specialized, high-volume institutions that focus on advanced treatments, surgeries, and critical care. Given their specialized nature, it’s natural that patients won’t stay in these hospitals indefinitely. Once their immediate medical needs are addressed, they must transition back to primary or secondary care for continued management.

To make these transitions smoother, tertiary hospitals must:

• Facilitate clear communication between referring physicians and specialists. This ensures that patient history and treatment plans are shared effectively.
• Enhance interoperability through Electronic Medical Records (EMR) integration. A seamless digital system allows different healthcare providers to access patient records, reducing redundant tests and improving efficiency.
• Implement structured discharge and follow-up planning so that patients receive continuous care after leaving the tertiary hospital.

These steps ensure that patient care does not stop at the hospital doors but instead continues in a structured and coordinated manner.

The Impact of Government Policy on Referral & Transfer

In South Korea, the Tertiary Hospital Structural Reform Pilot Program is reshaping the way patients move through the healthcare system. Under this initiative:

• Referrals from primary care clinics to tertiary hospitals are still allowed, but they no longer receive additional financial incentives.
• Referrals from secondary hospitals to tertiary hospitals, however, now come with additional financial incentives.

This policy is designed to optimize patient flow, ensuring that tertiary hospitals focus on high-acuity cases while primary and secondary hospitals manage less complex conditions. It reflects a shift toward a tiered healthcare system that strengthens each level of care rather than overloading tertiary hospitals with cases that could be handled elsewhere. (At least in theory, this makes sense. However, in reality, it may not always function positively. I will address this in a future post.)

Why Continuity of Care Matters for Patient Outcomes

Does all of this restructuring actually improve patient health? The research says yes.

• A Korean study found that stronger CoC reduces preventable hospital admissions and helps patients manage chronic diseases more effectively (Seoul National University study).
• Another study showed that diabetic patients who experienced higher CoC had significantly lower hospitalization rates for avoidable complications (DBpia research).

These findings highlight why ensuring CoC isn't just about system efficiency—it’s about real, measurable improvements in patient health.

Addressing Misconceptions: Are Tertiary Hospitals Abandoning Patients?

One major concern when discussing referral and transfer policies is patient perception. Many patients and their families misinterpret transfers as hospitals giving up on them. This couldn’t be further from the truth.

Tertiary hospitals aren’t abandoning patients; they are ensuring that each patient receives the right care in the right place. The goal is to provide specialized treatment when necessary and then transition patients back to a setting where their long-term health can be managed effectively.

To avoid misunderstandings, healthcare providers must:

• Clearly explain why a transfer is happening. Patients should know that they are not being rejected but rather being directed to the most appropriate level of care.
• Provide a structured care plan so that patients and their families understand the next steps.
• Use technology, such as telemedicine and digital follow-ups, to keep patients engaged even after they leave the tertiary hospital.

Patients deserve to feel confident that their care is continuous, well-planned, and patient-centered—not abrupt or disconnected. (Korean patients seem to have a stronger tendency to feel this way compared to those in other countries. I will explore the reasons behind this in a future post.)

The Future of Continuity of Care: Where Do We Go from Here?

To further strengthen CoC, the healthcare system needs to:

• Enhance interoperability so that medical records can be seamlessly shared between providers.
• Leverage digital health tools such as telemedicine and AI-driven patient tracking.
• Educate healthcare providers on the importance of CoC and train them to handle referrals and transfers with patient-centered communication.

Technology and policy reforms alone won’t solve the problem—a cultural shift in how we approach patient transitions is also necessary.

Tertiary hospitals play a vital role in continuity of care, not just by providing specialized treatments but also by ensuring patients transition smoothly back to primary or secondary care when needed.

The Tertiary Hospital Structural Reform Pilot Program aims to create a well-balanced, multi-tiered healthcare system that allows each level of care to function at its best. Meanwhile, interoperability and patient-centered communication will be key to making these transitions successful.

At the heart of all these efforts is a simple truth: continuity of care leads to better patient outcomes, and every stakeholder in the healthcare system has a role in making that happen.