Milestone 8: Practice facilitates referrals to appropriate community resources, including community organizations and agencies as well as direct care providers.
Goal: Practice has completed its resources inventory and consistently links patients with appropriate community resources and follows up on referrals made.
Change Drivers
Vet all potential referral providers and agencies
Leverage personal relationships to cultivate referral opportunities
Maintain an inventory of community resources that may be available to patients
Work with community agencies to enhance services available to patients
Maintain formal (referral) links to community-based chronic disease self-management support programs, exercise programs and other wellness resources with the potential for bidirectional flow of information
Provide a guide to available community resources
As a provider, employ the philosophy “You should only refer to a provider you would send your loved one to”
Create and maintain referral lists for medical residents in academic settings
Engage local health coalitions to identify resources in areas where resources are scarce
Find out how patients define quality of care and build those definitions into the practice model
Maintain a referral tracking system to assure “loop closure” (i.e. that patients make and keep appointments and that a report is received)