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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 patient-centered medical home.  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.

Key changes, activities, and resources

At a glance

Key changes:
#1 Decide as a primary care clinic to improve care coordination.
#2 Develop a tracking system for referrals.
Develop a quality improvement 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.
• NCQA Care Coordination Process Measures [PDF]
• Care Coordination Questions from Validated Instruments [PDF]
• Referral Tracking Guide [PDF]
More about key changes #1 and #2
#1: Decide as a primary care clinic to improve care coordination.
Fragmented care can cause dangerous delays and other mishaps in care, is often a source of duplicated and unnecessary service, in addition to potentially frustrating patients.
Deciding to improve care coordination means being prepared to redeploy and train staff in new roles, reach out to other key providers and service agencies, and enhance information flow between the practice and other providers.  The next step is to develop a QI plan with clear goals—such as 100 percent return of consultation reports, or contacting patients within three days of hospital discharge.
#2: Develop a tracking system for referrals. 
An important component of assuming accountability is being able to monitor referrals and transitions to ensure they happen in a timely way.  Tracking referrals means developing a paper-based or electronic system to record all referrals and key steps toward their completion. 
A tracking system begins by recording basic information about each referral or transition, including specialist consults, hospitalizations, ER visits and community agency referrals.   The next step is to develop a way to assess and record key milestones as they’re reached: Did Ms. G keep her appointment with the psychiatrist?  Has the practice received the psychiatrist’s report?  Which patients were seen in the ER last week?  Have they been contacted by the practice nurse?

Learn more

  • Download the complete toolkit [PDF]
  • View the NCQA Process Measures—care coordination indicators for medical home certification [PDF]
  • View the Care Coordination Questions from Validated Instruments—a selection of questions from major patient experience questionnaires [PDF]
  • View the American College of Physicians Center for Practice Improvement and Innovation’s practical guide for tracking referrals  [PDF]