U.S. Department of Health and Human Services

National Diabetes Education Program

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Improve Referrals and Transitions

In the absence of coordination, tests may be duplicated, problems may be overlooked, medications with adverse interactions may be prescribed, and patient safety may be threatened. Six elements associated with effective care coordination suggest that successful referrals and transitions should be:

Timely: Patients receive needed transitions and consultative services without unnecessary delays.
Safe: Referrals and transitions are planned and managed to prevent harm to patients from medical or administrative errors.
Effective: Referrals and transitions are based on scientific knowledge, and executed well to maximize their benefit.
Patient-centered: Referrals and transitions are responsive to patient and family needs and preferences.
Efficient: Referrals and transitions are limited to those that are likely to benefit patients, and avoid unnecessary duplication of services.
Equitable: The availability and quality of referrals and transitions does not vary by the personal characteristics of patients.

Source: www.improvingchroniccare.org/index.php?p=Care_Coordination&s=326

A Diabetes Care Coordination toolkit provides quality improvement approaches that a practice can use to ensure care coordination for people with diabetes. The tool kit includes continuous quality improvement approaches, flow sheets, referral letters, patient information, resources, and references.

American College of Physicians (ACP) provides a 2010 position paper to address the gaps that exist in care coordination when a physician refers a patient to a specialist: The Patient-Centered Medical Home Neighbor: The Interface of the Patient-Centered Medical Home with Specialty/Subspecialty Practices.

AHRQ Publication No. 11-0064. Rockville, MD: Agency for Healthcare

The Endocrine Society’s Managing the Transition of Care for Patients with Type 1 Diabetes
This resource provides a number of materials to help with transition of care specific to type 1 diabetes.

Research and Quality. 2011: Coordinating care in the medical neighborhood: critical components and available mechanisms.

NDEP resource to help teens with diabetes make a smooth transition from pediatric to adult health care.