The Medical Neighborhood

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At its core, patient-centered care is not only establishing systematic and proactive care within the walls or your practice but also working on behalf of your patients with the community to coordinate care. The medical neighborhood can include other physicians, specialists, mental health providers, dental/vision providers, hospitals, community resources, social workers, pharmacists, home health care providers, complex case managers, peer programs, and other community supports. The focus is set on the patient while care is accomplished by the medical neighborhood team. Developing the external structure includes establishing relationships to build the medical neighborhood, discovering the types of resources found in the community, setting up communication channels which can enhance patient care and decrease duplication or errors, and tracking referrals, test results, and medications, for overall patient care.  
Resources:
Referral Forms and User Resources:  
The intent of this guide is to identify the fields and values needed when completing the Referral Form. It includes a legend with definitions along with step by step directions for submission.  
Description of programs that are offered to help patients improve their own health in partnership with their primary care physician.  
Other Resources:
BCBSGA worksheet introducing the concept of medication reconciliation and related implementation strategies. 
This template referral form provides a way to standardize and track referrals.  
This template form is one example of a standard form to send to specialists to facilitate care coordination.  
An example of a formatted checklist (adapted from the Colorado Medical Society Compact Facilitation Guide) that can be used when making referrals as compacted relationships are established.  
 
 
 
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