Tool 13: Community Resource Guide Tool

Purpose: Develop an updated resource guide of community resources relevant to providing posthospital supports and services to avert readmissions.

Description: This tool is modeled on a community resource guide developed by a community-based care management agency. It prompts the hospital readmission reduction team to identify specific contacts at community agencies to facilitate efficient referrals to services.

Staff: Hospital readmission team, cross-continuum team.

Time required: 10 hours.


The first step to using community resources to address patients' social and behavioral health needs is to identify community agencies and other organizations that can help meet those needs. Many hospitals perceive that there are limited or no community resources available, without ever having made a concerted effort to look for these resources. This tool will help you populate a resource guide to quickly and efficiently connect patients to the services they need.

Starting on the next page is a template to fill in the information about your community resources. This resource guide will be especially helpful to the discharge coordinators, community health workers, patient advocates, volunteers, or other people who will help patients address their basic needs. Once completed, an abbreviated version of the most common referrals/resources used can be added to the Whole-Person Assessment Tool.

To populate this resource guide, draw from the following information sources:

  1. Your cross-continuum team partners. A highly useful function of your cross-continuum team is to ask them to help populate an inventory of community-based services that can meet the clinical and nonclinical needs of Medicaid patients after hospitalization. Their knowledge and experience with these services will help in creating efficient linkages to care from the hospital.
  2. Key contacts at Medicaid health plans. Representatives from Medicaid health plans should be invited to the cross-continuum team meetings, but depending on geography, they may not be able to attend in person as the local service providers can. A clinical/quality leader at the hospital (e.g., director of quality) should identify a key contact at each Medicaid health plan who can update and clarify the types of supports and services the plan can provide and for which types of patients. Most important, the hospital and each plan should develop a clinical (not just utilization review) point of contact to facilitate time-sensitive discussions about posthospital supports and services to reduce readmissions.
  3. Your hospital social workers. Social workers are trained to understand the comprehensive landscape of social services in a community. Over time, hospital-based social workers may benefit from inservices or networking with community-based colleagues to refresh connections and understanding of available programs and resources, as this is a continuously changing landscape in any community.
  4. A search engine. Conducting an online search for community resources in your area can be a quick way to find potential partners and their contact information. This can be a useful research method in addition to what the social workers and cross-continuum team partners are aware of.
  5. 2‐1‐1. Most of the United States has access to 2-1-1, a telephone hotline that specializes in health and human services information and referral. This can also be a useful supplemental method of research for hard-to-find community resources.

Resource Guide for [Hospital Name]

Health Clinics

Name / Contact Person Phone Number Address Assistance Offered
[Community Clinic A] [555-555-5555] [123 Street, City]  
[Mental Health Center B] [555-555-5555] [123 Street, City]  
[Health Department C] [555-555-5555] [123 Street, City]  
[Sickle Cell Foundation D] [555-555-5555] [123 Street, City]  
[AIDS Health Center E] [555-555-5555] [123 Street, City]  
[Community Dental Clinic F] [555-555-5555] [123 Street, City]  
[Dental School G] [555-555-5555] [123 Street, City]  

Substance Abuse Treatment

Name / Contact Person Phone Number Address Assistance Offered
[Alcoholics Anonymous A] [555-555-5555] [123 Street, City]  
[Narcotics Anonymous B] [555-555-5555] [123 Street, City]  
[Methadone Clinic C] [555-555-5555] [123 Street, City]  
[Recovery Home D] [555-555-5555] [123 Street, City]  

Housing and Rent Assistance

Name / Contact Person Phone Number Address Assistance Offered
[Religious Organization A] [555-555-5555] [123 Street, City]  
[Housing Authority B] [555-555-5555] [123 Street, City]  
[Community Agency C] [555-555-5555] [123 Street, City]  
[Women and Children's D] [555-555-5555] [123 Street, City]  
[Temporary Shelter E] [555-555-5555] [123 Street, City]  

Financial Assistance

Name / Contact Person Phone Number Address Assistance Offered
[Community Assistance Program A] [555-555-5555] [123 Street, City]  
[Charity B] [555-555-5555] [123 Street, City]  
[Religious Organization C] [555-555-5555] [123 Street, City]  
[Salvation Army D] [555-555-5555] [123 Street, City]  
[Employment Office E] [555-555-5555] [123 Street, City]  
[Career Center F] [555-555-5555] [123 Street, City]  

Food Assistance

Name / Contact Person Phone Number Address Assistance Offered
[Community Assistance Program A] [555-555-5555] [123 Street, City]  
[Charity B] [555-555-5555] [123 Street, City]  
[Meals on Wheels C] [555-555-5555] [123 Street, City]  
[Salvation Army D] [555-555-5555] [123 Street, City]  
[Religious Organization E] [555-555-5555] [123 Street, City]  
[Career Center F] [555-555-5555] [123 Street, City]  

Nonemergent Transportation Assistance

Name / Contact Person Phone Number Address Assistance Offered
[Cab Company A] [555-555-5555] [123 Street, City]  
[VA Clinic B] [555-555-5555] [123 Street, City]  
[Community Agency C] [555-555-5555] [123 Street, City]  

Nonmedical Home Care Agencies

Name / Contact Person Phone Number Address Assistance Offered
[Home Care Agency A] [555-555-5555] [123 Street, City]  
[Community Agency B] [555-555-5555] [123 Street, City]  

Legal Assistance

Name / Contact Person Phone Number Address Assistance Offered
[Medical Legal Partnership A] [555-555-5555] [123 Street, City]  
[Company B] [555-555-5555] [123 Street, City]  
[Community Agency C] [555-555-5555] [123 Street, City]  

Children's Services

Name / Contact Person Phone Number Address Assistance Offered
[Immunization Agency A] [555-555-5555] [123 Street, City]  
[Religious Organization B] [555-555-5555] [123 Street, City]  
[Parenting Assistance Group C] [555-555-5555]    
[Early Development Services D] [555-555-5555]    
[Community Daycare Services E] [555-555-5555]    
[Children's Insurance Program F] [555-555-5555]    
[YMCA/YWCA G] [555-555-5555] [123 Street, City]  

Medicaid Assistance

Name / Contact Person Phone Number Address Assistance Offered
Customer Service Office A] [555-555-5555] [123 Street, City]  

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Page last reviewed August 2014
Page originally created August 2014