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Health practitioners and providers play a major role in ensuring that the appropriate exchange of information is coordinated. An effective referral system ensures a close relationship between all levels of the health system and helps to ensure people receive the best possible care closest to home. It also assists in making cost-effective use of hospitals and primary health care services. Referrals can be done via fax, phone call, e-referral through an Electronic Health Record, or by providing the patient with a referral directly.
It is important to ensure that Standard Operating Procedures (SOP) are disseminated and understood by all staff in order to ensure that they are followed for the maximum benefit. Methods for communicating this SOP include:
- reviewing annually at an all-staff meeting
- including within training materials for new hires
- including a copy of the policy in an employee email
- inclusion within an employee handbook
- posting to the facility's intranet website for employees
Implementation of Culturally and Linguistically Appropriate Services (CLAS) standards are a strategy toward advancing health equity, improving quality and eliminating health care disparities. To meet this benchmark, facilities may select any of the following strategies:
- Provision of staff training, sometimes referred to as cultural sensitivity or diversity training
- Utilization of bilingual providers
- Utilization of bilingual family members and support staff
- Utilization of professional medical interpreters
- Utilization of telephonic interpretation services
- Provide printed materials in the language of your population
- Assess health literacy of your patient population
Patient-centered care is defined by the Agency for Healthcare Research and Quality as a partnership among practitioners, patients and their families that ensures that decisions respect patients' wants, needs and preferences, and that patients have the education and support they need to make decisions and participate in their own care.
Healthcare facilities are encouraged to focus on the following educational areas as a way to offer patients self-management strategies and empower patients to manage their own care when it comes to chronic disease: cancer screening/services, hypertension screening/management, diabetes screening/management, prediabetes, fluoride treatment, oral health preventive care, weight management, nutrition education, physical activity education, HPV vaccination, screening tools (prediabetes, diabetes, heart health).
To meet this benchmark, facilities must submit documentation or a picture to illustrate their method of dissemination. Acceptable dissemination methods include:
- placing information in waiting room or lobby
- hanging posters in waiting room or lobby
- posting information in patient portal
- discussing with patient at discharge by clinician
- handing materials to patient at discharge by front-desk staff
- making available at front-desk
Click here for patient education resources.
Diabetes Self-Management Education and Support (DSMES) Program curricula can help patients adopt healthy behaviors, manage disease symptoms and prevent further disease progression.The National Diabetes Prevention Program (NDPP) curricula can help patients adopt healthy behaviors to prevent the onset of type 2 diabetes. These lifestyle change programs are known to be more effective then providing patients with education during physician visits or at hospital discharge, as they incorporate self-care principles and provide a group setting to give individuals the emotional support needed to make lifestyle changes.
Healthcare facilities may demonstrate collaboration with one of the following DSME training or prevention programs:
Healthcare facilities should encourage patients to seek care beyond their provider visit stay by providing referrals to DSMES and NDPP programs. Ideally, the DSMES and NDPP programs will report back to the referring provider.