Approaches to Enhance Community Resource Referrals

To support this strategy, members are encouraged to:

• Vet all referral partners and agencies to ensure they provide respectful, inclusive, and high-quality care.

• Cultivate relationships with local service providers by leveraging personal and professional networks to strengthen referral pipelines.

• Maintain a living inventory of community resources—medical, mental health, social services, housing, food access, transportation, and more.

• Collaborate with community agencies to expand what’s available to patients, particularly in under-resourced areas.

• Establish formal partnerships with chronic disease self-management programs, exercise and wellness services, and culturally competent support programs—ensuring two-way communication when appropriate.

• Distribute a user-friendly community resource guide to help patients and families connect with services on their own time.

• Adopt a values-based referral mindset: Only refer patients to providers or programs you would confidently recommend to a loved one.

• Create and maintain trusted referral lists for medical trainees and care teams, especially in academic or residency settings.

• Partner with local health coalitions to uncover hidden resources or co-develop services in areas where options are limited.

• Ask patients what “quality of care” means to them, and incorporate those definitions into referral practices.

• Implement a referral tracking system to ensure loop closure—confirming patients access the services they were referred to and that feedback is received from the partner organization.