Case summariesVignettes, profiles and testimonial videos

ToolkitsImplementation guides and other documents with extensive resources included

  • Toolkits

    Enhancing Communication in Primary Care Prospectus

    Learn how one LEAP site, part of West County Health Centers, partners with specialists through telehealth consults. This communication toolkit describes the ways that technology can be used to coordinate with external providers and roles of primary care team members (Page 13), technology requirements (Pages 21-24), billing guidelines in California (Pages 25-29), and general telehealth resources (Pages 37-46).


  • Publications

    Medical Neighborhood Implementation Guide

    One LEAP site created this comprehensive Medical Neighborhood implementation guide to facilitate communication and agreements between primary care and specialty practices. This resource will help you improve coordination of your patients' care by providing background information and review of the evidence, example templates, and considerations of a care coordination agreement, and how to monitor and continually improve the relationship within that agreement.

  • Publications

    Closing the Loop with Referral Management

    LEAP site The Wright Center has a referral manager who tracks referrals in the EHR. Exception reports to ensure that the loop is fully closed, meaning that consult notes from the specialist have been received. The practice also has a social worker care coordinator who helps address patient barriers to completing a specialty visit. See how the practice uses EMR to manage referrals or watch a webinar for more information:


  • Video

    Referral Management at St. Luke's Eastern Oregon Medical Associates

    Learn how one LEAP site manages referrals by watching this video. At St. Luke's Eastern Oregon Medical Associates, a dedicated referral manager coordinates with patients and specialists to ensure that patients get the care they need. Furthermore, the practice has workflows and systems in place to "close the loop" on all referrals, so that all specialist services are documented in the primary care medical record.

Role featuresJob descriptions, career ladders and other HR materials

  • Role features

    Referral Coordinator Job Description

    See an example job description for a referral coordinator, based on elements of this role we saw across LEAP sites. The referral coordinator tracked all aspects of referrals, including receipt of consult notes and medical records following specialty visits.

Clinical protocolStanding orders, risk stratification forms and hospital transition protocols

  • Clinical protocol

    Referral time expectations

    See how one LEAP site “risk stratifies” the urgency of referral information to ensure that patients and specialists are aware of the time sensitivity involved and how to best communicate to meet the patient's medical needs.

  • Clinical protocol

    Specialty Referral Request Checklist

    See how one LEAP site prepares for referrals, by using a checklist of needed items to provide to specialists with each outgoing referral.

WorkflowTemplates, flow sheets and mapping aids

  • Workflow

    Referral workflow

    See an example workflow for the referral process, involving a designated referral manager of a primary care practice, helping patients keep and make appointments, exchanging information with specialists, and closing the loop.

  • Workflow

    Referral cover page

    LEAP site St. Luke's Eastern Oregon Medical Associates is meticulous about closing the loop on referrals. As part of that work, the referral coordinator faxes referral materials to specialists with this cover page, which prompts specialists to confirm that the referral information was received and that the patient has an appointment.