What is the challenge?

Many patients receive referrals to different providers and services—including community resources, specialists, labs, emergency departments, and hospitals. When referrals don’t get completed or fail to provide the information sought, it upsets patients and frustrates providers. Referrals can be inefficient, ineffective, and even dangerous unless the process is well coordinated, with all parties communicating and sharing timely information.

What needs to change?

Primary care practices must be the hub for all the services their patients receive. This means:

  • Be accountable for ensuring that all referrals meet the time sensitive needs of the patients and their providers. This requires developing a trusted referral network and staff roles, workflows, and information systems to track and manage referrals.
  • Support patients by making sure they get the information and care they need. This includes helping them find and schedule services, as well as tracking progress and results.
  • Establish relationships with different providers and service organizations in the community to build trust and develop shared expectations for referrals.
  • Develop connections with other providers and organizations who care for your patients to facilitate interaction and the timely flow of patient information.

What do we gain by making these changes?

By making these changes, practices help patients get the services they need when they need them, and ensure that providers get the information they need when they need it—at the lowest cost to the patient and the health system. These changes are important steps toward improving patient outcomes while the work becomes more efficient and less stressful.

Referral Management at St. Luke's Eastern Oregon Medical Associates

  1. Select and train staff to track and manage referrals.

    Many high-performing practices train a member of their front desk or administrative team to become a “referral manager” who orchestrates and tracks the progress and outcomes of referrals. Referral managers should be good communicators who work well with patients and providers—both inside and outside the practice. They should also be familiar with the practice’s information systems and time expectations for various referrals, and be willing to take persistent action to facilitate and track referrals.

  2. Reach out to specialists, hospitals, and community service agencies.

    Start by identifying the specialists, hospitals, and community service agencies that the practice and its patients use and value the most. Then initiate conversations with them to strengthen the relationship and better understand each other’s preferences and expectations about which patients to refer, how to make appointments, what information to send, and care arrangements after the initial consultation. It’s sometimes helpful to develop written agreements. Some LEAP sites, especially those in more rural settings, were able to bring consulting services to their patients by either having specialists see patients in the primary care clinic or obtaining specialist input through telehealth technology.

  3. Create workflows to ensure the referral loop gets closed.

    The referral loop is not closed until the patient has the services they need and the referring practice has the information they sought. Referral workflows should begin by ensuring that patients understand the reason for referral, and are willing to go. The practice should then route all referrals through the referral manager so that they can be tracked. As part of this process, the referral manager helps patients make and keep appointments and works with referring providers and consultants to ensure the timely two-way flow of information needed to complete the referral process. Practice policies should designate a process for addressing patient and/or provider barriers to loop closing.

  4. Develop standard ways of exchanging referral information.

    The referral manager is responsible for managing the flow of information back and forth between the referring practice and the specialist or community agency. The first step is to develop or select a system for communicating important referral information consistently and efficiently. The system can be low-tech or high-tech—what matters most is that it meets the needs of both parties. Helpful approaches include using standardized forms, a shared electronic health record, or e-referral software.

Case summariesVignettes, profiles and testimonial videos

ToolkitsImplementation guides and other documents with extensive resources included

  • Toolkits

    Enhancing Communication in Primary Care Prospectus

    Learn how one LEAP site, part of West County Health Centers, partners with specialists through telehealth consults. This communication toolkit describes the ways that technology can be used to coordinate with external providers and roles of primary care team members (Page 13), technology requirements (Pages 21-24), billing guidelines in California (Pages 25-29), and general telehealth resources (Pages 37-46).


  • Publications

    Medical Neighborhood Implementation Guide

    One LEAP site created this comprehensive Medical Neighborhood implementation guide to facilitate communication and agreements between primary care and specialty practices. This resource will help you improve coordination of your patients' care by providing background information and review of the evidence, example templates, and considerations of a care coordination agreement, and how to monitor and continually improve the relationship within that agreement.

  • Publications

    Closing the Loop with Referral Management

    LEAP site The Wright Center has a referral manager who tracks referrals in the EHR. Exception reports to ensure that the loop is fully closed, meaning that consult notes from the specialist have been received. The practice also has a social worker care coordinator who helps address patient barriers to completing a specialty visit. See how the practice uses EMR to manage referrals or watch a webinar for more information: http://www.safetynetmedicalhome.org/change-concepts/care-coordination


  • Video

    Referral Management at St. Luke's Eastern Oregon Medical Associates

    Learn how one LEAP site manages referrals by watching this video. At St. Luke's Eastern Oregon Medical Associates, a dedicated referral manager coordinates with patients and specialists to ensure that patients get the care they need. Furthermore, the practice has workflows and systems in place to "close the loop" on all referrals, so that all specialist services are documented in the primary care medical record.

Role featuresJob descriptions, career ladders and other HR materials

  • Role features

    Referral Coordinator Job Description

    See an example job description for a referral coordinator, based on elements of this role we saw across LEAP sites. The referral coordinator tracked all aspects of referrals, including receipt of consult notes and medical records following specialty visits.

Clinical protocolStanding orders, risk stratification forms and hospital transition protocols

  • Clinical protocol

    Referral time expectations

    See how one LEAP site “risk stratifies” the urgency of referral information to ensure that patients and specialists are aware of the time sensitivity involved and how to best communicate to meet the patient's medical needs.

  • Clinical protocol

    Specialty Referral Request Checklist

    See how one LEAP site prepares for referrals, by using a checklist of needed items to provide to specialists with each outgoing referral.

WorkflowTemplates, flow sheets and mapping aids

  • Workflow

    Referral workflow

    See an example workflow for the referral process, involving a designated referral manager of a primary care practice, helping patients keep and make appointments, exchanging information with specialists, and closing the loop.

  • Workflow

    Referral cover page

    LEAP site St. Luke's Eastern Oregon Medical Associates is meticulous about closing the loop on referrals. As part of that work, the referral coordinator faxes referral materials to specialists with this cover page, which prompts specialists to confirm that the referral information was received and that the patient has an appointment.