Milestone 11 Summary

Description: Practice facilitates referrals to appropriate community resources, including community organizations and agencies as well as direct care providers. 


What does success look like?


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Practice does not regularly refer patients to available community resources. Practice is compiling an inventory of resources and establishing communication with them to link patients with appropriate community resources. Practice is referring patients to appropriate community resources but does not have a consistent approach for following up on referrals made. Practice has completed its resources inventory and consistently links patients with appropriate community resources and follows up on referrals made.

Note: numbers are PAT scores


Why is this important?

Referrals to community-based services and specialists are an important component of coordinated care; such services are often vital components to successful treatment and care management plans. Many patients may need assistance obtaining services that are outside the scope of their primary care provider’s domain, such as food or housing assistance, resources to address substance use, transportation assistance, help to escape domestic violence, and many other resources to address needs according the a patient’s social determinants of health. Connecting patients with chronic illnesses or disabilities may help them to better manage day-to-day activities, better integrate into their community, and improve outcomes. However, poorly coordinated referrals can be frustrating to patients and even dangerous by promoting fragmented care, especially as provider referral networks continue to grow.1 Specialists are often concerned about the appropriateness of referrals2,3 while primary care providers often remain in the dark when their patients are seen in an ED or admitted to the hospital.3,4 Referral management is essential to care coordination and often leads to greater patient and provider satisfaction.


Potential Tactics

  • Take stock of community connections and foster collaborative relationships
  • Designate an individual or team to be responsible for coordinating community resources
  • Create a list of community resources and contact each one to verify services provided
  • Create a standardized workflow for documenting referrals made and services obtained by patients
  • Identify a process to screen patients for their social, legal and other non-health needs
  • Build off of risk-stratification and empanelment infrastructure to integrate referral documentation into the patient medical record


Tools and Resources

What might this look like in practice?

A clinic in Humboldt Park, Chicago, Illinois decided to implement a referral management process to help connect patients to community resources based on feedback from their patient advisory board that many patients lacked access to safe ways to exercise. First, a task force was created to curate a list of all community resources available on the west side of the city. Next, each community-based organization was contacted by a member of the task force to verify services provided and to establish a point of contact. When available, collaborations including discounted rates to publically available service such as gyms or parks were negotiated.  This information was documented in a centralized location and reviewed by the task force to prioritize and reduce the resource list by responsiveness, proximity, and breadth of services available.

This list of community resources was then uploaded into the electronic medical record and categorized by service provided (i.e. obesity reduction, smoking cessation, group behavioral therapy services). A workflow was piloted and rolled-out to screen each patient for unmet social and behavioral needs during their clinic appointment. Upon documentation in the medical record of these needs, a tailored list of available resources was generated to meet the specific needs indicated. Documentation of resource discussion and recommendations was then completed for review and follow-up at the next clinic appointment. Patient feedback was used to further prioritize the resource list and to direct clinic resources towards fostering stronger community collaborations.



  1. Implementation Guide: Care Coordination- Reducing Care Fragmentation in Primary Care. Safety Net Medical Home Initiative. May 2013. Available at
  2. Cummins RO, Smith RW, Inui TS. Communication failure in primary care. Failure of consultants to provide follow-up information. JAMA.1980;243(16):1650-1652.
  3. Gandhi TK, Sittig DF, Franklin M, Sussman AJ, Fairchild DG, Bates DW. Communication breakdown in the outpatient referral process. J Gen Intern Med. 2000;15(9):626-631.
  4. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831-841.
  5. Bright Futures Implementation Tip Sheet: Community Resources- Community Resources Checklist. American Academy of Pediatrics. Available at: