Chronic Conditions - Key Activity 22


Continue to Develop Referral Relationships and Pathways


This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; proactive patient outreach and engagement; care coordination; behavioral health integration; address social needs.


Delivery of primary healthcare encompasses not only preventive services and coordination of medical and behavioral healthcare but also referrals for social supports, dental care and other needs of patients, such as weight management or parenting programs. As a result, coordination of care is more complex and often involves referrals outside the practice structure. Examples include referrals from the practice to a clinician, such as medical specialty clinicians, or behavioral health and social service providers, such as the Supplemental Nutrition Program for Women, Infants, and Children; CalFRESH; CalEarn; the Employment Development Department for paid family leave; or to a program that will support health and well-being. A referral network also includes acute and subacute facilities, such as hospitals, emergency departments and residential treatment facilities where a patient may receive treatment and the outcome of treatment is necessary for the ongoing care of the patient in the practice.

This activity addresses common steps that your practice can take to optimize both the referral pathways and outcomes. The practice of closed loop referrals, in which there is a feedback mechanism to ensure that a referral made by one provider to another is completed and followed up appropriately, leads to greater patient and provider satisfaction. This activity builds on an inventory of existing referral services outside the clinic and identifies steps that can be taken to support the systematic management of the referral process.

When a patient requires a referral to obtain needed services outside the clinic, the process is a point of vulnerability. A significant percentage of specialty referrals are not completed, in part due to missing information, misguided referrals and faulty communications.[1][2] If a referral is not completed, patients may not receive needed services, which can lead to decreased quality of care, decreased patient and clinician satisfaction, and ultimately poorer health outcomes.[3] The National Committee for Quality Assurance (NCQA) recognizes the importance of referral networks and their management as a core component of Patient Centered Medical Home activities.[4] Building a reliable network of service partners and processes to provide information necessary to inform referrals as well as having mechanisms to track referral results are important parts of providing coordinated care that is person centered.

A contributor to inequity in health outcomes is unequal access to specialty services and resources to help patients with their condition.[5] The heart of this activity is to empower both the care team and patients through development and maintenance of a robust process to help patients access medical, behavioral health and community resources.

Many factors can impact whether or not a patient accesses a referral, including language, culture and lack of understanding of why referral is being requested. Lack of understanding of why a referral is being sought is often a barrier for patients to follow up with a referral, particularly if a patient is not experiencing symptoms.

When appropriate, referrals for social needs and to community health programs can help address barriers, including those around transportation, language, and basic needs of food and housing stability, all of which are associated with poorer health outcomes. Action steps and roles

Action steps and roles

1. Identify types of referral partners that your practice needs and gaps in resource availability.

  • Some examples to consider: high-volume specialties such as ophthalmology, podiatry, dermatology, social services clinicians, substance use clinicians.
  • In areas where you have gaps in referral clinicians, telehealth services may be an option. For further information on telehealth services – including e-consult and synchronous, asynchronous and e-visits – contact your MCP and/or refer to the Telehealth Reimbursement Guide for California (Pages 14 to 16). Referral processes and tracking are also important to establish for telehealth as well as in-person services.
  • Note that there is a shortage of behavioral health clinicians in many parts of California. As you continue to expand your network of off-site behavioral health clinicians to meet pressing behavioral health needs, also consider behavioral health integration strategies, including expanding your practice’s capacity for providing integrated behavioral health services. See the PHMI People with Behavioral Health Conditions Guide for more about deepening and expanding integrated care.
  • Work with the care teams for patients with diabetes and hypertension to identify gaps in referral resources that could enhance implementation of evidence-based care.
  • Use social health screening results that have been disaggregated by REAL and SOGI alongside patient/family feedback to identify unmet needs for which resource relationships have not been established.


2. Assess what tools would be beneficial for the core elements of your referral process.

Examples include: (see resources below)

  • Referral request form:
    • Determine what information is required for the clinician who is receiving the referral. Information may include the requested service; timing (urgent vs. standard); minimum necessary information, such as patient contact information and applicable demographics; and appropriate clinical and social support questions.
  • Referral tracking spreadsheet or software:
    • Information in a tracking system can include date of referral, appointment status and whether follow-up is needed. Reach out to your Medi-Cal MCPs as you are developing referral tracking processes. The MCPs are required to show that Medi-Cal patients are being connected to the services that they are eligible for and referred to; this includes preventive services, specialty services and social services. The MCP may be a good resource for tools, such as those needed for tracking and reporting.
  • Referral workflow diagram:


3. Assess what tools would be beneficial in enhancing and tracking your referral process.

  • Referral guidelines:
    • For social services, positive responses to screening questions/tools may be the prompt for referral. Other types of referrals may be optimized by having documented referral guidelines, such as information needed by a specialty clinician in order to best answer a referral question.
  • Communication templates:
    • For high-volume or frequent referral types, a standardized template for communication between the clinic and referral staff can help ensure that essential information is conveyed efficiently. Examples may include referral letters, progress notes and post-visit summaries of plan of care.
  • Patient education materials (develop in conjunction with referral network):
    • Educational materials and resources for patients that explain the referral process and what to expect can enhance patient understanding and support referral completion. In addition, consider training MAs as well as any dedicated care coordination staff in evidence-based communication techniques, such as teach-back or motivational interviewing to leverage team-based care in supporting the patient to follow through with the referral after the visit.


4. Develop approaches to fill resource gaps.

Suggested team member(s) responsible: care team.

  • Outreach to your Managed Care Plan (MCP) to understand what resources are available. MCPs are required to have online clinician directories that include specialists, which can be a resource used by a clinic to help find contracted specialists near the patient's home. In addition to comprehensive networks of over a dozen core specialty clinicians and information on behavioral health and substance use resources, many MCPs are building links to access community-based resources in addition to the 14 Medi-Cal Community Supports through referral platforms that act as a hub to coordinate social needs for patients.
  • Identify external clinicians and community resources that can serve as partners in care, and use the established referral process to fill gaps in care they can address.
  • Meet/schedule time with high-volume clinicians, including community-based organizations, to develop a mutual understanding of the goals of referrals and opportunities for development of a shared process (e.g., referral form).
  • The American Academy of Pediatrics offers a sample tool to develop a resource list.


5. Regularly review and update the referral processes and network.

Suggested team member(s) responsible: clinic leadership.

  • As new patient needs are identified, use that opportunity to identify potential resources and expand the referral network. If practices have trouble accessing a contracted specialist for their patient because of overly long wait times or because the specialist may not be accepting new patients, the MCP is required to approve an out-of-network referral to a specialist who is more available.
  • On a periodic basis, review referral tracking reports to identify referral resources that are used most frequently, and use that information to reinforce the relationships and provide feedback on value.
  • Review referral tracking reports to identify resources for which loop closure is lacking or from whom required information is not being received on a regular basis. Outreach to these organizations to reinforce expectations, or if necessary, identify a replacement resource for the network.
  • For going deeper in tracking QI metrics, practices can develop metrics to assess the effectiveness of the referral network. This might include tracking referral completion rates, patient satisfaction and time from referral to specialist appointment.


  1. Weiner M, Perkins AJ, Callahan CM. Errors in completion of referrals among older urban adults in ambulatory care. J Eval Clin Pract. 2010;16(1):76-81. doi:10.1111/j.1365-2753.2008.01117. 
  2. Mehrotra A, Forrest CB, Lin CY. Dropping the baton: specialty referrals in the United States. Milbank Q. 2011;89(1):39–68. doi: 10.1111/j.1468-0009.2011.00619. 
  3. Mehrotra A, Forrest CB, Lin CY. Dropping the baton: specialty referrals in the United States. Milbank Q. 2011;89(1):39–68. doi: 10.1111/j.1468-0009.2011.00619. 
  4. Transitions of care [Internet]. 2023 [cited 2024 Feb 8]. Available from:  
  5. Cai C, Gaffney A, McGregor A, Woolhandler S, Himmelstein DU, McCormick D, et al. Racial and ethnic disparities in outpatient visit rates across 29 specialties. JAMA Internal Medicine. 2021 Nov 1;181(11):1525. doi:10.1001/jamainternmed.2021.3771