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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 create 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.

Key changes, activities, and resources

At a glance
Key changes:
#3 Organize a practice team to support patients and families during referrals and transitions.
Delegate/hire staff to coordinate referrals and transitions of care, and train them in patient-centered communication, such as motivational invterviewing 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.
• Referral Coordinator Job Description [PDF]
• Referral Coordinator Curriculum [PDF]
• Patient Referral Checklist [PDF]
• The Care Transitions Program® [link]
• Patient Activation Assessment Form [PDF]
•  The Post-Hospital Follow-up Visit:  A Physician Checklist to Reduce Readmissions [link]
More about key change #3
#3: Organize the practice team to support patients and families during referrals and transitions.
The goal of care coordination in the PCMH is to keep the patient at the center of care during referrals and transitions.  It’s important that practices handle the patient support functions of care coordination separately from clinical care management—even though many nurses or other care managers provide patient support along with their clinical responsibilities.  Most clinical follow-up or care management programs focus on a small, higher-risk subset of a practice’s panel—and do not address the patient support needs of those who are less ill.
Patient support tasks will vary with the needs of the population served, and staff who provide patient support will need skills and training tailored to meet those diverse needs.  Some practices can successfully distribute care coordination tasks among team members, but most benefit from designating a specific person—a referral coordinator—to handle patient support tasks and using an electronic referral tracking system.
For each referral or transition, the referral coordinator assembles the needed information, including the patient’s clinical, demographic, and insurance details.  The coordinator also helps patients make appointments—identifying any barriers related to language, lack of transportation, etc., and helping find ways to overcome them.  Lastly, the coordinator keeps track of all referrals and transitions and quickly intervenes when problems arise, such as when a patient doesn’t show up for a specialist appointment or when a consultative report is not received.

Learn more

  • Download the complete toolkit [PDF]
  • Read the sample Referral Coordinator Job Description [PDF]
  • Read the Referral Coordinator Curriculum [PDF]
  • Dive deeper into the Care Transitions Program®, which contains valuable information about supporting patients after hospital discharge [link]
  • Review The Patient Activation Assessment Form [PDF]
  • Read The California HealthCare Foundation's issue brief describing the ways primary care clinicians can support patients post-dischard [link]