Overview
This toolkit provides detailed, practical guidance for primary care organizations developing or improving processes for referring patients with identified non-medical needs to community resources. It is designed to help clinic teams move from screening to an organized referral process that fits their local resources, staffing, and workflows.
What the Resource Covers
The toolkit guides clinic leaders, administrators, and staff through four key decisions involved in designing a non-medical needs referral program. It addresses how to connect patients with community resources, maintain accurate, up-to-date information about available services, develop workflows to support patients in accessing referred services, orient staff, and evaluate the program. The toolkit is evidence-based, was pilot-tested in three diverse primary care clinics, and includes activities that enable clinic teams to collaborate to adapt referral processes to their own settings.
Key Takeaways for Implementation
Effective referral programs require more than identifying a patient’s needs and providing contact information for community services. Clinics need clear workflows, reliable resource information, defined staff responsibilities, and processes that help patients successfully connect with services.
Who May Find This Resource Useful
This resource may be especially useful for primary care practices and health systems seeking detailed, step-by-step guidance on designing, implementing, or improving referral programs that connect patients with services that address non-medical needs.
Resource Type: Tools & Toolkits.
Topic Areas: Needs referrals, primary care, community resources, workflow design, program implementation.
Population or Setting: Primary care practices and health care organizations.
Publication Date: July 2024.
Source: Oregon Health & Science University and OCHIN BRIDGE-C2, Washington University ISC3, Harvard University ISCCCE, Caring Health Center, and University of Washington OPTICC.
