Community-based referral intervention: Lessons learned in Northern Minnesota

In the first iteration of the Statewide Health Improvement Program in Minnesota, a legislative health reform initiative, key informant interviews were conducted with providers to capture information about the screen, council, referral, follow-up process. In a pilot assessment of barriers to clinic-community referral flow, these interviews were adapted into a survey which 158 providers answered (6.4% response rate). Participants were recruited using the Minnesota Academy of Family Physicians e-newsletter and a targeted search of physicians in the Community Transformation Grant zip code area using the Minnesota Board of Medical practice database. Providers received either a paper or electronic copy of the survey. While 69.2% of participants reported they were interested in referring patients to community-based resources and 49% reported they preferred that more community-based services were available, 47.9% identified being unaware of programs or services as a barrier to making referrals. Additionally, only 11% of providers reported referring all or most of their at-risk patients to community-based programs. In an effort to utilize these findings, the Minnesota Department of Health contracted with Stratis Health to implement an intervention to strengthen community-clinic connections for referral and follow-up. Working with 4 clinics in northern Minnesota, this intervention seeks to help clinics develop community-clinic action plans and to improve health information technology systems. The goal of the intervention is to increase referrals to and follow-up with patients referred to community-based resources for preventive services. Partnership processes and lessons learned are discussed.