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Care Coordination
and Referrals

How nurses connect patients to the right people, services, and settings to ensure safe, continuous, and effective care.

NCLEX-RN

What Is Care Coordination?

Care coordination is the deliberate organization of patient care activities between two or more participants involved in a patient's care. It ensures the right care is delivered at the right time, in the right place, by the right people.

Key Terms

Referral
Directing a patient to another provider or service for specialized care the patient needs.
Case Management
Coordinating services across the continuum to optimize outcomes and control costs.
Continuity of Care
Consistent, uninterrupted care as a patient moves between settings or providers.

Why It Matters

Hospital Acute Care Home Health Follow-up Rehab Therapy Specialist Referral

The Nurse as Coordinator

1
Assess the patient's needs and resources across physical, social, and financial domains.
2
Communicate with the interdisciplinary team and document accurately.
3
Advocate for appropriate referrals and services that match patient goals.
4
Evaluate whether referrals were completed and outcomes were met.

The Interdisciplinary Team

Core principle: Each referral must go to the discipline whose scope of practice matches the patient's specific need. Matching the need to the right team member is the heart of effective coordination.

PT / OT
Mobility, ADLs, strength, fine-motor rehab.
Dietitian
Nutrition therapy, diet teaching, tube feeding plans.
Social Worker
Finances, housing, discharge planning, resources.

The Referral Process

Identify Need Get Order Communicate Follow Up

Referral vs. Consultation

Referral Consultation
PurposeTransfer some care to a serviceGet expert advice/opinion
Care HandoffYes, partial transferNo, primary team keeps care
ExampleRefer to home healthConsult wound care nurse
OrderUsually requiredUsually required

How to Apply It

1
Identify the specific need first. What exactly is the patient missing?
2
Match the need to the discipline whose scope addresses it.
3
Confirm the order and provide a clear, complete handoff (SBAR).
4
Verify and evaluate that the referral was completed and helped.

Example 1: Matching Needs

An 82-year-old patient is being discharged after a hip fracture repair. She lives alone, cannot climb stairs safely, and is worried she cannot afford her new medications.

Example 2: Prioritizing

A new mother with a premature infant will go home today. She needs feeding teaching, has signs of postpartum depression, and lacks transportation to follow-ups.

First Priority
Postpartum depression: safety risk. Notify provider for mental health referral.
Then
Lactation consult for feeding; social work for transport resources.

Example 3: Transitions

A patient is transferring from the ICU to a medical-surgical floor. The receiving nurse must understand the patient's status, lines, and pending tasks.

Common Mistakes

✕ Wrong Discipline
Referring a financial problem to PT instead of a social worker.
✕ No Follow-Up
Placing a referral but never verifying it was completed.
✕ Skipping the Order
Acting without the provider order a referral requires.

Quick Reference

Patient Need Refer To
Mobility, gait, strengthPhysical Therapy
ADLs, fine motor skillsOccupational Therapy
Swallowing, speechSpeech-Language Pathology
Diet, nutrition therapyRegistered Dietitian
Finances, housing, resourcesSocial Worker
Spiritual/emotional supportChaplain / Counselor

Question 1 of 5

A patient recovering from a stroke struggles to dress and feed himself. Which referral is most appropriate?

Question 2 of 5

After placing a home health referral, what is the nurse's final responsibility in the process?

Question 3 of 5

A patient cannot afford medications and has no transportation home. The nurse should refer to the:

Question 4 of 5

During an ICU-to-floor transfer, which tool best ensures critical information is not lost?

Question 5 of 5

A new mother shows signs of postpartum depression, needs feeding teaching, and lacks transportation. Which need does the nurse address first?

Key Takeaways

1
The nurse is the central hub coordinating the interdisciplinary team.
2
Match each need to the right discipline within its scope of practice.
3
Most referrals require a provider order and a clear handoff.
4
Always follow up and evaluate to ensure continuity of care.