Care Coordination


  • When Multiple Practices or Clinics are Involved in a Patient’s Care, All Must Collaborate – but One Must Assume Overall Responsibility for Organizing the Care. Establishing Conditions and Infrastructure to Assure Effective Referrals and Transitions is a Core Responsibility of the PCMH. Referrals are more Likely to be Successful When All Providers Understand Each Other’s Expectations and Preferences – and When Adequate Staff and Information Infrastructure Exist to Help Patients and Their Information Get Where They Need To Go
  • Develop A Quality Improvement (QI) Plan To Implement Changes And Measure Progress
  • Design The Clinic’s Information Infrastructure To Internally Track And Manage Referrals/Transitions Including Specialist Consults, Hospitalizations, ER Visits, And Community Agency Referrals
  • Continuity Of Care/Exchange Of Patient Information/Obtaining Discharge Summaries

Patient Support

Referrals And Transitions Challenge Patients And Families. They Raise Questions That Need To Be Answered, Generate Appointments That Need To Be Made, And Produce Logistical Challenges And Anxiety That Need To Be Addressed. Practices That Dedicate Staff Time To Meeting These Patient Needs Are More Likely To Have Successful Referrals And Transitions. After Each Procedure And Where Appropriate, Each Patient Will Be Offered Education In Rehabilitation, Nutrition/Dietician Services, Exercise And Obesity Counseling As It Relates To Each Particular Case. Our Goal Is To Create The Best-Rounded Experience For Each Patient In Order To Optimize Their Health.

  • Organize A Practice Team To Support Patients And Families
  • Health Providers Available To Improve Care Coordination, Case Management, Nutrition And Education Classes
  • Delegate/Hire And Train Staff To Coordinate Referrals And Transitions Of Care, And Train Them In Patient Centered Communication, Such As Motivational Interviewing Or Problem Solving
  • Assess Patient’s Clinical, Insurance, And Logistical Needs
  • Identify Patients With Barriers To Referrals/Transitions And Help Patient Address Them
  • Provide Follow-Up Post Referral Or Transition
  • Implement Physician Checklist To Reduce Readmissions
  • Implementation Of A Standardized Process Of Medication Reconciliation
  • Training And Support In Best Possible Medication History
  • Assuring Medication Accuracy At Transitions In Care
  • Preventive Services
  • Monitoring Of Appointment Needs And Preferences
  • Same Day Appointment Availabillity
  • Extended Hours Of Care
  • After Hour Nurse Line, Phone And Web Messaging
  • Telephone Triage And Patient Education
  • Patient Transportation

Relationships & Agreements

Referrals And Transitions Work Best When All Parties-Patients, Primary Care Providers, And Consultants-Agree On The Purpose And Importance Of The Referral, And On The Roles That Each Will Play In Providing Care. As Close, Personal Relationships Between PCP’s and Specialists Or Hospital Staff Become Less Common

  • Integrate Preferred Provider Networks Optimizing Quality And Cost By Identifying, Develop, And Maintaining Relationships With Key Specialist Groups, Hospitals, And Community Agencies
  • Develop Verbal Or Written Agreements That Include Guidelines And Expectations For Referral


To Support Successful Referrals And Transitions, All Providers Involved Must Have The Information They Need To Optimize Care And A Trustworthy Way Of Communicating. An Electronic Referral System Can Help Assure That Critical Information Flow Occurs In A Timely Way And Can Incorporate Agreed Upon Guidelines For Referrals And Transitions.

  • Develop And Implement An Information Transfer System
  • Implementation of EMR/PM And Medical Algorithms
  • Use A Shared Electronic Health Record Or Web-Based Referral System
  • Optimizing Referrals & Consultations Reports With A Standardized Process