Ensuring quality referrals and effective care coordination

Effective two-way communication between primary and subspecialty care practices can improve referrals and care coordination for both by making some basic infrastructure adjustments.


Internists have always comanaged care with subspecialists, but as practice transformation has moved into the spotlight, so has the importance of care coordination. Moving from disconnected “silo” care to a connected system of care is a step in right direction for practice transformation.

The medical neighborhood and care coordination are now high priorities in the new Medicare payment system and thus are a critical aspect of practice improvement plans. The goal is to establish efficient communication in both directions. This will maximize benefit to the patient in terms of quality care as well as in cost and efficiency for all involved.

Effective two-way communication can improve referrals and care coordination for both primary and subspecialty care practices by making some basic infrastructure adjustments. But before a practice can set up a new system, it is important to analyze the current referral processes. Write down every step along the referral pathway, from the point of deciding that a patient needs to be referred out to a subspecialist until the patient is back under your care again. Where are there failures? How do you know if patients went to see the subspecialist?

Likewise for the subspecialty practice: Start with how referrals come in and continue through the process to the point of sending the patient back to the referring practice. Look for gaps. Something as simple as not getting the correct demographic information on the patient before the visit can create roadblocks in care coordination. Do the patients understand why they are there? It is important for physicians to fix problems in their own practices first and to involve their entire teams so that effective changes can be put in place.

Armed with the “wish list” of information that would help either the referring primary care practice or the subspecialty practice, the team can develop a checklist that the practice staff can use as a guideline. Define specifically who is on the referral team and create a policies and procedures document that the team can use (and refine over time). Define what data are needed for each patient (basic demographics, insurance, medications, allergies, etc.) and for each referral (based on certain subspecialties or conditions). It is important to include protocols on how to close the loop at the end of the referral by establishing clear processes for communication, responsibility, and data transfer (if using an electronic health record).

If there are certain practices that you work with, work together to develop an agreement that clarifies what is needed on both ends and defines roles and responsibilities. These processes can be designed in whatever way works best in your practice, using paper forms, electronic templates, or a combination of both. Doing all of these things will ensure that the patient gets high-quality care as efficiently and expeditiously as possible.

ACP's High Value Care Coordination (HVCC) Toolkit provides resources to facilitate more effective and patient-centered communication between primary care and subspecialist doctors, including referral checklists, pertinent data sets for certain conditions, and care coordination agreements. The toolkit was the work of the HVCC Project, a collaboration between ACP's Council of Subspecialty Societies (CSS) and patient advocacy groups.