For a referral or discharge, identify the next action, the person responsible and how completion will be confirmed. A closed-loop referral includes follow-through; sending a request alone does not establish that care was received.
Move care between teams
Plan discharge, reconcile medications and clarify what the receiving team accepted.
- Nursing Discharge Planning · Transitional Care Nursing
- Medication Reconciliation and Care Transitions · Warm Handoffs Between Care Teams
- Closed-Loop Referrals · Follow-Up After Hospital Discharge
- Care Plans Across Organizations
Choose a service or setting
Distinguish a referral from eligibility, enrollment or an available place.
- Home Health Eligibility and Referrals · Hospice Referral and Enrollment
- Palliative Care Referrals · Skilled Nursing Facility Transitions
- Inpatient Rehabilitation Transitions · Long-Term Acute Care Hospital Transfers
- Medical Respite Programs
Support caregivers and address barriers
Identify needs that may prevent a person from using the agreed care plan.
- Caregiver Readiness for Discharge · Caregiver Strain Assessment
- Community Resource Referrals · Screening for Health-Related Social Needs
- Food Insecurity and Healthcare Referrals · Transportation Barriers to Care
- Housing Instability and Care Planning
Coordinate across communities and evaluate results
Find guidance for disability support, rural services, school communication and measures of follow-through.
- Care Coordination for People with Disabilities · Rural Care Coordination
- School-to-Healthcare Communication · Measuring Care Coordination
Sources
- IHI and NPSF: Closing the Loop on Ambulatory Referrals (accessed 2026-11-11)
- AHRQ: Make Referrals Easy (accessed 2026-11-11)
- CMS: Hospital Discharge Planning, State Operations Manual Revision 238 (accessed 2026-11-11)