Worksheet Under constructionCriterion 43 concerns explaining a referral so the client understands the reason, what it means for their participation, and what happens next. A person may welcome additional support or may hear the recommendation as another rejection after difficult experiences with care. Ask how they understand the situation and give them time to respond. The SPIKES communication framework offers a structure that can be adapted from its original oncology setting (Baile et al., 2000). The explanation must remain accurate about the finding, the program's limits, and whether services are continuing, paused, or ending.
Learning Objectives
By the end of this module, the trainee will be able to:
- Explain the referral decision and connect the conversation with selection, confidentiality, and assistance.
- Describe how the explanation, timing, and follow through may affect the client's understanding and trust.
- Adapt the SPIKES communication framework to an appropriate referral conversation.
- Name the unmet need specifically and transparently rather than in vague or evasive language.
- Explain whether the referral adds support, postpones participation, changes the service, or ends it.
- Locate the reason in the need and the program's limits rather than in the client's deficiency.
- Support client autonomy through options, questions, and the client's right to decline.
- Adapt tone and pacing to a population with reason to distrust institutional care.
- Prepare a written referral explanation from verified information and record the client’s response.
- Assign the next action and review access barriers, disagreement, and program concerns.
Key Terms
Rationale. The reason a referral is being made, communicated to the client in a way that is specific, truthful, and intelligible, so that the client understands what is happening to them and why.
Response to a referral. The client's reaction to a proposed change in care, which may include relief, uncertainty, disappointment, fear, or disagreement. Ask rather than assuming the news is unwelcome.
Accurate explanation. A clear account of why the referral is proposed, whether current services will continue, and what decisions remain unresolved.
Effect on participation. Whether the referral adds care, changes the service, pauses participation, or ends the service the program can provide.
Locating the reason. Placing the cause of the referral in the client's need and the program's limits rather than in a deficiency of the client's character, which preserves dignity while remaining accurate.
Autonomy support. Giving the client understandable information, time for questions, and meaningful choices, including the choice to decline a referral. The program remains responsible for its own service decisions.
Specific explanation. An account naming the relevant finding, unmet need, and action required in language the client can understand.
The alliance. The working relationship between facilitator and client, which a well explained referral can strengthen and a poorly explained one can rupture, regardless of how clinically correct the referral itself was.
Core Teaching
Understanding the client’s response
A referral can bring relief when it addresses a concern the client has struggled to get recognized. It can also feel like dismissal, particularly after repeated transfers or poor care. Ask what the person understands about the concern and what the recommendation means to them. Explain the finding using the client's report and the information available to the program. Describe the competence or resources needed to address it and why the current service cannot provide them. The conversation may influence trust, but the explanation alone cannot determine how the client feels or compensate for a referral that is inaccessible. Practical follow through remains part of the work.
Naming the concern
Use a concrete description of the finding. For example, explain that the reported chest tightness needs medical assessment, that the program does not provide medication management, or that continuing suicidal thoughts require qualified care. Distinguish a reported symptom from a diagnosis. State the urgency and what the person should do next; active chest symptoms should not be left with an ordinary future referral. Vague references to “fit” or “readiness” can leave the client unsure what happened or what could change. If the reason cannot yet be determined, explain the uncertainty and the assessment needed.
Describing the program’s limitation
Explain which capability is missing and whether the limitation belongs to the individual facilitator or the program. A client may need a clinician the site does not employ, monitoring it cannot provide, or a service outside its authorization. Describe the relevant condition or circumstance without making a judgment about the person's character. A useful explanation gives the client something they can check and act on. It also makes clear that a recommendation for further assessment is not a diagnosis or a promise that another provider will approve participation.
Explaining continued support
If some services can continue, name them and explain their limits. The client might remain in individual integration support while receiving clinical treatment elsewhere, provided that arrangement is appropriate and responsibilities are agreed. Say who will contact whom, what information can be shared, and when the plan will be reviewed. If the program cannot continue providing a service, explain the transition arrangements and how the client can obtain help during the interval. Reassurance should describe an actual commitment the program can keep.
Questions and decisions
Invite questions and ask what may make the referral difficult. Discuss suitable options and the client's preferences. An adult with the relevant decision making capacity may decline recommended care, although a refusal does not require the program to offer a service it cannot safely provide. Explain the consequences for participation and document the decision without punitive language. When there is immediate danger or a concern about capacity, follow the applicable emergency procedures and law with qualified help. Ordinary referral conversations should allow time for a person to consider the recommendation rather than treating an immediate yes as the only acceptable response.
Giving the client an account they can act on
State the decision, the reason, and what happens next in ordinary language. Tell the client whether a service is continuing, paused, changed, or ending. If further assessment is needed, explain the question it should address. Avoid giving a definite diagnosis unless you are qualified and have made that assessment. “The chest symptoms need medical assessment” is a different statement from “You have a heart condition.”
If the decision may be reviewed, explain the review process. Name the information required, who reviews it, and how the client will receive an answer. A clinician's letter may contribute to the decision without guaranteeing admission. Explain this before the client spends time or money obtaining it. If the program cannot offer the service under any foreseeable circumstances, say so rather than asking for repeated clearances that will not change the outcome.
Give a brief written account when appropriate and agree on a safe way to send it. Include the service status, the referral purpose, contact details, and the next planned communication. Ask the client to describe what they understand will happen. This may reveal that they think the referral is optional while participation continues, or that they believe all support has ended when it has not (Agency for Healthcare Research and Quality, 2024; Talevski et al., 2020).
Emotion and disagreement
Acknowledge the specific loss or inconvenience the client describes. You may know that they traveled and paid; you cannot know the full personal cost unless they tell you. Say what you understand and leave room for correction. The client may need a pause, an interpreter, a support person, or a later conversation. Ask before involving someone else.
The SPIKES framework was developed for communicating difficult information in oncology (Baile et al., 2000). Its attention to setting, understanding, information, emotion, and planning can help organize a referral discussion. It does not require every referral to be presented as bad news, and its use here is an adaptation. An emergency may require action before a private, extended conversation is possible.
Listen to disagreement for new information. A client may identify a factual error, an accommodation that was overlooked, or a resource the program did not consider. Review those points through the appropriate process. A wish to avoid conflict should not lead staff to proceed without required care, but a safety explanation should also remain open to correction when its factual basis is wrong.
Money and the care decision
Explain refunds, credits, deposits, travel arrangements, and cancellation terms separately from the clinical or safety reasoning. Refer the client to the person authorized to resolve financial questions. Avoid making a refund conditional on accepting the facilitator's interpretation of the event or waiving a complaint. When a policy is unclear, give a date for an answer instead of improvising a promise.
A client may ask whether payment can secure an exception or additional supervision. Any proposed change needs the same review of qualifications, capacity, and authorization as the original plan. Money cannot substitute for an unavailable service. If an accommodation or different setting could meet the need, explain the actual option and its limits without using the referral discussion to sell another package.
When the receiving service cannot see the client soon
Name the gap and discuss what can safely happen during it. The client may need an earlier general clinical assessment, a different provider, or urgent care if symptoms worsen. Confirm who is responsible for follow up and what the current program will continue to offer within its role. Do not describe peer support as equivalent to treatment that is medically necessary.
End the conversation with a practical question: “What will you do next, and is anything likely to get in the way?” Agree on the contact date and safe method. If the client declines the referral, clarify their reasons and check whether the decision rests on a misunderstanding or an access problem. Record the decision accurately. The client can decline a recommendation; the program remains responsible for stating its own service limits clearly.
Preparing the explanation from the record
Before the conversation, check the information on which the referral is based. Identify the original report, its date, the question it addressed, and the person who interpreted it. Resolve obvious inconsistencies with the responsible practitioner. A client should not have to discover during a difficult conversation that the program used someone else's laboratory result or an outdated medication list.
Agree internally on the actual service decision and who can reconsider it. Prepare to explain the specific concern, the requested assessment or support, the timing, and the effect on current participation. If staff disagree, arrange the appropriate review before presenting a settled conclusion. When immediate safety requires action, state what is known and arrange help while the remaining questions are clarified.
Writing a referral explanation the client can use
Give the client a brief written account after the discussion when appropriate. Include the concern in ordinary language, the purpose of the referral, the current status of services, the next contact, and any practical arrangements already made. If participation depends on a further assessment, specify the question that assessment must address. Avoid asking for a generic clearance that leaves the receiving clinician guessing what the program intends to do.
Check names, telephone numbers, dates, and the safe delivery method before sending it. Ask whether the wording captures the client's understanding and record any disagreement. The client may choose to use this account when contacting another service. Explain whether it is an informational summary or a formal referral requiring additional records, and who will arrange those records under the appropriate authority.
Responding when the client declines
Ask what is behind the decision. The client may disagree with the reason, fear stigma, be unable to afford the appointment, or have already arranged care elsewhere. Correct factual misunderstandings and discuss feasible alternatives. Explain the effect on the program's own service without using threats, shame, or a loss of unrelated support to obtain agreement.
Record the recommendation, the explanation given, the client's stated reason, any alternatives offered, and the next agreed action. Refusal should not become a catchall label for an appointment the person could not access. If there is a concern about capacity or immediate danger, involve the appropriate clinician or emergency service. Follow the relevant process for the actual situation and document the assessment or advice obtained.
Handling questions about program error
A referral may follow a problem the program contributed to. Explain the current care need and address the person's questions about the event. Keep the known facts separate from matters still under review. Give them an appropriate contact for the complaint and an independent care option when they do not want further contact with the practitioner involved.
Practical support should continue according to the care plan while the complaint is considered. Tell the client when they should expect an update and who can resolve financial questions. Preserve the record of the event and later explanations. A change in the program's understanding should be communicated plainly, with the corrected information and its effect on the plan.
Checking that the conversation led somewhere
After the discussion, enter the next task into the referral process. Record who will call, what information can be shared, when contact should occur, and who will check the result. Send the agreed written information promptly. If the client wanted time to think, record when and how the program will reconnect within the agreed limits.
During supervision, review an example of the actual explanation and its outcome. Ask whether the client could identify the reason and next step, whether the service status was accurate, and whether the promised assistance occurred. A polished conversation can still leave a person stranded when nobody makes the next call. Use the review to correct the process as well as the wording.
Clinical and Decision Tools
Tool 1 Tasks surrounding the referral conversation
The explanation draws on the identified need and leads into resource selection, privacy decisions, and assistance.
Criterion | The work |
|---|---|
42 | Identify the need this facilitator or program cannot meet |
43 | Explain the rationale for the referral to the client |
44 | Match the need to an appropriate resource |
45 | Protect confidentiality through the process |
46 | Assist the client in actually using the resource |
Tool 2 A structure for the conversation SPIKES adapted
Adapt the steps to the person's condition and preferences. Urgent care takes priority over completing the sequence (Baile et al., 2000).
SPIKES component | Adaptation for a referral discussion |
|---|---|
Setting | Arrange privacy and adequate time when possible; urgent care takes precedence |
Perception | Ask what the client understands about the concern |
Invitation | Ask about the information and communication support they need |
Knowledge | Explain the finding, uncertainty, and service decision clearly |
Empathy | Listen to the response and acknowledge what the client describes |
Strategy and summary | Confirm next steps, responsibilities, and understanding |
Tool 3 Explaining the effect on participation
State whether care is being added, participation is paused, or services are ending.
Service decision | What the client needs to know | Follow through |
|---|---|---|
Additional support | What continues and what the referral will add | Identify the receiving service and coordination plan |
Participation postponed | What is paused and what assessment or change is required | Explain review, practical arrangements, and interim support |
Service ending or unavailable | The reason and what the program can still provide | Arrange appropriate transition and explain any review process |
Before speaking, confirm which commitments and options the program can actually offer.
Tool 4 Describing the reason for referral
Use the reported concern, relevant findings, and the specific capability the program lacks.
Unclear or judgmental wording | More useful information |
|---|---|
I have some concerns | Name the symptom or requirement and the assessment needed |
You are too unstable | State the care needed and what the program cannot provide |
You are not ready | Explain the current finding and decision without judging character |
Lengthy defense of the program | Give the reason, invite questions, and address the response |
Tool 5 Client choice and program responsibility
Explain the client's choices and the service limits that remain in place if the referral is declined.
Client choice | Program responsibility |
|---|---|
The client can ask questions and disagree | Review new information and explain the basis for the decision |
The client can choose among suitable options | Describe verified options and their limits |
The client can decline a referral | State what services can or cannot continue and follow applicable safety duties |
Tool 6 Referral conversation checklist
Confirm the explanation was truthful, specific, well located, and humane.
Check | Done? |
|---|---|
Immediate needs addressed and an appropriate communication setting arranged | Yes / No |
Client's understanding and communication needs checked | Yes / No |
Specific concern and uncertainty explained | Yes / No |
Service status stated clearly | Yes / No |
Any future review requirements and limits explained | Yes / No |
Reason described without a judgment about the client's worth | Yes / No |
Response heard; practical consequences discussed | Yes / No |
Next step, responsible person, and understanding confirmed | Yes / No |
Written referral explanation
Element | Content | Check with the client |
|---|---|---|
Reason | Specific finding and the question requiring help | What do they understand about the concern? |
Service status | Continuing, changed, paused or ending | What do they expect will happen today? |
Next step | Resource, assistance, timing and responsibility | What practical barrier remains? |
Review | Information that could change the decision and who reviews it | Have costs and limits been explained before further assessment? |
Response | Agreement, disagreement, refusal or time requested | What will the program do next and when? |
Worked Example An Exclusion Told Honestly
This fictional example applies the practices discussed in this module.
Context: The client from Criterion 42, who disclosed exertional chest tightness on the morning of a ceremony. He has traveled, paid, and wants to proceed. He cannot. This is an exclusion, and the facilitator must say so.
Immediate assessment and privacy: Staff first check whether symptoms require emergency help. Once the person's immediate needs are addressed, the facilitator discusses the participation decision in a private setting with appropriate support.
Understanding the concern: The facilitator asks what the client has noticed and what they understand about the recommended assessment. They listen without treating minimization as proof that the symptom is harmless.
Explanation: Once immediate needs are addressed, the facilitator explains that the chest symptoms require medical assessment and the client cannot participate today. The appropriate medical service will determine what further evaluation is needed.
Service status: The facilitator states clearly that today's session is postponed. They explain what information is needed before any future participation can be considered, without promising that an assessment will guarantee admission.
Locating the reason: The reason is put where it belongs: in the symptom and in the program's lack of cardiac capability, not in any failing of the client's. He is not being judged, and his heart needs looking at.
Response: The client says he saved for a year and becomes upset. The facilitator acknowledges the disappointment and asks what help he needs now. Financial and travel questions are referred to the staff member who can resolve them.
Client choice and program responsibility: The client says he accepts the risk and wants to go ahead. The facilitator explains that he may decline the cardiology referral, and that the program cannot provide today’s session under the current conditions.
Strategy: He leaves knowing exactly what happens next. Where the referral goes, whether he can return, and on what condition, are the work of Criteria 44 and 46.
Case Vignettes
For each vignette, identify the concern, describe the response, and explain your reasoning. Record your responses on a separate page.
Vignette A
A client is being screened out for an uncontrolled medical condition. Wanting to spare her the disappointment, the facilitator tells her only that he would love her to add a doctor to her support team, and does not tell her she cannot attend the retreat. She arrives two weeks later expecting to participate.
Guided questions: What did the client need to know about participation? How should the decision and next steps have been communicated? How would you address the misunderstanding now?
Vignette B
A facilitator says only, “I have concerns about the fit.” The client is left unsure whether the issue is medical, personal, or administrative. The actual concern is a possible medication interaction requiring review by an appropriate clinician.
Guided questions: What did vagueness cost this client? What would specificity have given her? Why does a named finding preserve dignity better than a vague concern?
Vignette C
A client reacts to a referral with anger and tears, saying he has been passed around by professionals his whole life. The facilitator, feeling accused, begins explaining the program's policies and defending the decision at length. The client stops speaking and leaves.
Guided questions: Which step of the protocol was skipped? What was the client actually communicating? What does defensiveness signal to a client who is braced for dismissal?
Vignette D
A facilitator explains a referral by telling the client, “You're too unstable for what we do here.” The client, who has heard versions of this her whole adult life, hears a verdict on her worth rather than a fact about a program.
Guided questions: Where was the reason located, and where should it have been? Rewrite the sentence so it is equally honest and locates the reason accurately (C42's two levels).
Vignette E
A client refuses the recommended cardiology evaluation and insists on participating, saying it is his body and his choice. The facilitator, wanting to honor client autonomy, feels obliged to let him proceed.
Guided questions: Explain the client’s choices and the services the program can safely provide. Document the decision, any disagreement, and the next step.
Role Play and Practice Scripts
Practice with a partner or team, then exchange roles. Use fictional details and discuss the choices made in each response.
Checking the client’s understanding
Practice asking what the client understands about the concern, then explaining the decision. If the scenario involves current medical warning signs, arrange urgent care before an extended referral conversation.
Naming an exclusion honestly
Practice: “You cannot take part today. The chest symptoms you described need medical assessment, and we cannot provide that assessment here. Let's arrange the appropriate care and discuss what happens with your booking.”
Staying in the room with the reaction
The partner is upset about postponement. Acknowledge what they have told you about its consequences, pause, and ask what support would help. Avoid claiming that you know exactly how they feel or promising unlimited availability.
Discussing choice and service limits
Practice: “You can decline the recommended assessment. Our decision about today's session remains the same. I can explain the reason again or help you consider the available options.”
Additional Practice
A postponed service and a long wait
A client understands why a session is postponed but cannot afford the suggested assessment and thinks the program has ended all contact. The next specialist appointment is several months away.
Practice questions: Explain the service status, review options for appropriate interim care, and agree on the next contact. Include financial questions and check what the client understands.
Applied Record Exercise
A referral based on an old report
A client is told to obtain another assessment before participating. They explain that the program used an old report and that a newer clinician’s letter is already in the file.
Task: Check the source documents, arrange the necessary review, explain the current decision, and prepare a corrected written account with the next action.
Review: The trainee treats the correction as information to verify, updates the explanation, and documents the decision and any practical consequences.
Self Assessment and Reflection
Knowledge check
Describe the explanation a client needs after an unmet need is identified and before a referral is arranged.
Name the components of SPIKES and explain how they can be adapted to a referral discussion.
Explain how to communicate continued, postponed, changed, or ended participation clearly.
Explain why specificity preserves dignity better than vagueness.
Explain how to locate the reason for a referral accurately, and rewrite a wounding sentence so that it is both honest and well located.
Describe the client's choices and the program's responsibility for the services it provides.
Explain how you would check understanding and respond to emotion during the discussion.
Reflection
Recall a time you softened a hard truth to make a conversation easier. Whom did the softening actually serve?
How do you react when a client is angry with you? Do you stay, or do you start justifying?
Which conversation do you avoid most: telling someone they cannot proceed, or telling them why? What does that avoidance cost them?
Observed Practice Assessment
Ask the trainee to explain a referral based on an older report while the client disputes one of its facts and raises a refund question.
The trainee checks the source, routes the factual dispute appropriately, states whether current services continue or pause, and explains the referral purpose and urgency. Their written account is usable by the client and assigns the next contact. Financial questions reach the appropriate person without changing the clinical explanation.
Misrepresenting an exclusion as optional support, using a refund to pressure agreement, or recording an access barrier as informed refusal requires correction and reassessment.
The assessor records the scenario, date, work reviewed, observed performance, feedback, and any required practice. Use the ratings demonstrated, needs further practice, or not observed for each task. A verbal answer alone cannot establish performance on a task requiring demonstration. Confirm readiness only for the work assessed and within the trainee’s authorized role.
Summary
A referral explanation should leave the client knowing the concern, the service decision, and what happens next. State whether support continues, is postponed, or ends. Describe the finding without an unsupported diagnosis or judgment about character. Ask what the client understands, provide appropriate communication support, and listen to their response. The SPIKES framework can organize a difficult conversation when adapted to the setting; urgent care takes precedence. Address practical consequences, review new information, and explain the limits of any future reassessment. Confirm the next action, responsible person, and contact date.
References
Agency for Healthcare Research and Quality. (2024). Use the teach-back method: Tool 5. Health Literacy Universal Precautions Toolkit (3rd ed.). https://www.ahrq.gov/health-literacy/improve/precautions/tool5.html
Baile, W. F., Buckman, R., Lenzi, R., Glober, G., Beale, E. A., & Kudelka, A. P. (2000). SPIKES—A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer. The Oncologist, 5(4), 302-311. https://doi.org/10.1634/theoncologist.5-4-302
Talevski, J., Wong Shee, A., Rasmussen, B., Kemp, G., & Beauchamp, A. (2020). Teach-back: A systematic review of implementation and impacts. PLOS ONE, 15(4), e0231350. https://doi.org/10.1371/journal.pone.0231350