The goal of this tool is to suggest approaches to assess patients' need for additional services and how to identify community services.
Tips for Implementing This Tool
- Consider implementing Tools 18 and 20 together. Tool 20: Connect Patients with Literacy and Math Resources focuses on identifying educational resources. As the two tools involve similar action steps, it may be highly efficient to implement them together.
- Consider adjusting responsibilities among practice staff so a staff person can take on the role of helping patients with non-medial support.
- Develop relationships with frequently used social service agencies, case management agencies, and social workers, and include them in patients' care planning.
- Create a supportive atmosphere. Showing patients that you care and the practice wants to help with their most pressing problems so they can pay attention to their health will earn their trust.
- Explain to staff who feel, "This isn't our job," that patients will not be successful in achieving their health goals if they are confronting other major life issues, such as hunger or housing instability.
The goal of this tool is to give practices ideas for helping patients afford their medicine.
Tips for Lowering Costs of Medicines
- Set up a system to check whether prescribed medicine is covered by your patient's health plan. If you e-prescribe, your EHR may tell you whether a medicine is covered by the patient's plan. Sometimes a small change (e.g., from a cream to a gel) can make the difference between a medicine that is covered and one that is not.
- Encourage clinicians to consider whether a generic is a suitable substitute for a name brand or newer version of the drug. Whether your patient has insurance or is paying for medicines out of pocket, generics almost always save money. Explore setting e-prescribing system's default to generics, and make sure prescribing pads include a checkbox for generics.
- Discuss with patients whether the price differential for two similar medicines is worth it. For example, a new extended release version of a medicine may be considerably more expensive and the additional cost may outweigh the convenience to some patients.
The goal of this tool is to offer your practice a method for identifying patients in need of literacy and math assistance and for connecting them with these resources.
Tips for Getting Your Practice Ready
- Consider implementing Tools 18 and 20 together. Tool 18: Link Patients to Non-Medical Support focuses on identifying key resources to address patient needs that may influence health (e.g., housing, transportation). As the two tools involve similar action steps, it may be highly efficient to implement them together.
- Use educational sessions and training opportunities (e.g., all-staff training) to discuss a practice-wide strategy to connect patients to community resources.
- Do your research about the resources that exist in your community. Online searches are an efficient way to start. Just type "literacy classes," "adult education classes," or "ESOL [English for speakers of other languages] classes" and the name of your city, for a place to begin. Web sites suggested in the Toolkit and Web sites for your city and county departments of human services are good places to start.
- Building new EHR capacities can greatly ease the implementation of Tool 20. If possible, make changes to your EHR that allow you to:
- Flag patients who can benefit from a referral to literacy or math resources.
- Prompt staff to discuss resources with patients and make appropriate referrals.
- Document that a referral was made, such that you can run a query to help you track and follow up with patients to confirm that they have completed the referral.
- Generate a referral form that includes the–
- Name of the program.
- Phone number.
- Location and directions for how to get there.
- Information to help the patient know what to expect from the service.
The goal of this tool is to relieve patients of the burdens involved in being referred for care elsewhere and assure continuous care.
Tips for Implementing This Tool
- Convenience will be a key factor as to whether or not a patient completes a referral. Your patients may want referrals near where they live or where they work, so be prepared to offer a selection of locations.
- Many practices are hiring referral coordinators to manage referrals. The Improving Chronic Illness Site has a referral coordinator job description, curriculum, as well as a patient referral checklist to make sure patients are prepared.
- The Safety Net Medical Home Initiative's Care Coordination Implementation Guide provides resources for improving referrals and other care coordination processes.
- Behavioral health referrals may require extra attention:
- Patients may be less likely to complete behavioral health referrals because of stigma, resistance, lack of insurance coverage, or lack of support.
- Shortages of behavioral health providers exist in some communities. Establishing referral arrangements in advance can make it easier for your patients to gain access.
- Behavioral health professions are extremely protective of their patients' confidentiality, often exceeding standards of the Health Insurance Portability and Accountability Act. Develop procedures to support collaboration (e.g., routinely requesting patients to sign a consent form for exchange of information at the time of a referral).
- Establish a plan for patients experiencing emergencies.
- Explore alternatives to conventional referrals to specialists. Telemedicine is becoming an increasingly popular method for obtain consultations, especially in rural and underserved communities. For example Project ECHO uses multi-point videoconferencing to link primary care providers with specialists at academic medical centers.