In an effort to keep patients safe at home or to return them home safely, health care professionals often find that what is needed isn't a medicine or a medical procedure—it can be transportation to appointments or a hot meal when the family caregiver is at work. Community-based services can make the difference between a safe or unsafe discharge. Community-based services can safeguard against avoidable readmissions and make a caregiving situation livable for both the patient and the family caregiver. Making effective referrals to these services can benefit you as the health care provider, your health care organization, and the patients and family caregivers you support.
This guide provides a framework for making effective referrals, from needs assessment to follow-up, and includes an abbreviated list of resources for easy reference. A more extensive list of resources is also available.