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Implementing Comprehensive Primary Care Referral Tracking in a Patient-Centered Medical Home

Spahr, Jenny, DNP, RN, CPNP; Coddington, Jennifer, DNP, RN, CPNP; Edwards, Nancy, PhD, RN, ANP-BC; McComb, Sara, PhD, PE

doi: 10.1097/NCQ.0000000000000283

The Patient-Centered Medical Home care model emphasizes efficient, coordinated care distributed among interdisciplinary team members. One key function to care coordination is referral/test tracking. This study evaluated the referral practices in a nurse-managed Patient-Centered Medical Home primary care clinic. The major findings corroborate the need for a well-organized referral-tracking system that is centralized and contains safety nets to reduce the number of delayed or missed referrals.

United States Air Force, 10th Medical Group, United States Air Force Academy, Colorado Springs, Colorado (Dr Spahr) and School of Nursing (Drs Coddington and Edwards) and Schools of Nursing and Industrial Engineering (Dr McComb), Purdue University, West Lafayette, Indiana.

Correspondence: Sara McComb, PhD, PE, Schools of Nursing and Industrial Engineering, Purdue University, 502 N University St, West Lafayette, IN 47906 (

The authors declare no conflict of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Accepted for publication: July 1, 2017

Published ahead of print: August 24, 2017

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