Bright Spot: Centralized Wellness Referral Center-Linking Clinics to Community Resources

Photo by National Cancer Institute on Unsplash

This bright spot was originally published in the 100 Million Healthier Lives Change Library and is brought to you through partnership with 100 Million Healthier Lives and the Institute for Healthcare Improvement.


Detailed Description

The Wellness Referral Center was created to quickly and easily connect primary care providers, regardless of whether they belong to large health systems, Individual/family practices, or federally qualified health centers, with resources for their patient's chronic disease management. These community-based, lifestyle intervention resources are vetted, informed by evidence, and address social, economic, and cultural barriers to participation for patients and their families. We work with community partners to identify and build resources, and partner with clinics to train and develop infrastructure and processes. The main component of this intervention is the central facility housing the call center and up-to-date resource list, the Wellness Referral Center. Clinics currently use fax machines to transmit referrals to the WRC and the WRC returns reports to clinics via secure email. The Wellness Referral Center uses a cloud-based Customer Relationship Management (CRM) program called Salesforce as a data collection, analysis, and program monitoring system. Providers and clinics can use secure logins to access their patient's participation data in real-time. Clinics are beginning to integrate participation information into their EHR systems. Incentives are given for participation through, quarterly drawings for fit-bits and refurbished laptops. In its first year of operations, the Wellness Referral Center (WRC) has connected over 700 patients to programs that help them prevent and manage chronic disease through healthy eating, active living, and other skills such as stress management.

Expected Outcomes

Primary providers and care teams can expect greater participation by their patients in lifestyle and behavior change activities including physical activity and exercise, chronic disease self-management, nutrition education, and more healthful shopping, cooking, and eating habits. Because patients can bring their caregivers, family members, and friends to classes that are at convenient times and locations, to free classes provided in their language, there is social and community support for patients to complete classes and to make lasting healthy behavioral changes. Increased follow-up and feedback to the provider on patient adherence and participation in clinically adjacent community programs.


Emerging bright spot (emerging evidence)

Key Lessons Learned

"When working with a clinic, you want to make sure that you develop a trusting, working relationship with them. You don't want to make the referral process cumbersome or 'another thing that they have to do.' Because your goal is to create a human habit of providers referring to the WRC, which is essentially creating a systemic change within the clinic, you want the process to engage them and eventually make it their own project. Allowing the space for this process, you will create ownership, which then leads to the development of leaders, which then results in sustainability. While allowing the flexibility in the clinic's own referral procedures and what the referral form can look like, be sure to get a clear understanding from your Evaluation Team of what data needs to be collected on that referral form in order to accurately report your numbers to funders and other stakeholders. Be prepared for things to not go smoothly right away. Do not be tied to what YOU create because it is something that the clinic needs to create. Also, mistakes will happen along the way; I call them "Learning Opportunities" because that's exactly what they are. If something doesn't work out, let's talk about it, figure out another way to possibly remedy it, and then move forward. This is something that is new for everyone, and if you are able to create that working environment right away, your success will be greater because people will feel more comfortable bringing their ideas and struggles to the table. Our partnerships are key when it comes to developing all of this, especially our communication work. It is because of our Provider Champions that we've been able to get our foot in the door to talk to the care teams, and they are readily available to give us input and feedback to any communication material that we develop. One of the big lessons that we've learned thus far is that although a clinic may be doing great with their referral process, they still need our support. With on-boarding several clinics (we went from 1 to 13 in one year) our attention became more focused on the newer clinics. Although our Champion clinics were doing well, they had new staff come on board, other staff left, and there was still a need for our technical support. We also saw that our monthly in-person meetings where they were to bring their challenges, concerns, successes, and mentor others had almost zero attendance. These Learning Opportunities brought us to create "Virtual Huddles"- which are monthly conference calls - they just use their own jargon for such meetings. These have been better attended, but we still see a need to somehow better advocate for these conversations, which is why we also now schedule quarterly site visits. At these site visits, we supply them with more referral forms, and are available to answer any questions, as well as provide any necessary training to new referring providers." - Valerie Quintana, community Health Manager - community & Clinical Linkages, Center for Community Health, Presbyterian Healthcare Services.

Cost Details

Estimated operating costs for the Wellness Referral Center are approximately $60/per new referral per month at the current volume. Intervention operations and implementation is directly supported by a portion of the approximately 2.9 million dollar cooperative agreement for 3 years with the Centers for Disease Control Racial and Ethnic Approaches to community Health (REACH) that established the Healthy Here: Communities Leading Healthy Change Coalition. Additional funds, including those from a BUILD health grant provided funding for groundwork, partnership building, and planning necessary for implementation. New contracts for managed care populations provide additional funds. Additional in-kind support is provided by each of the partner organizations. New grants and contracts are sought to sustain and expand programming. Incentives currently include laptops and fit bits. Adelante Development Center, Inc. the organization that houses the WRC donates refurbished laptops. Presbyterian donates fit bits.

Key Steps for Implementation

There are five steps to how the WRC works:

  1. Patient Centered Care - The primary provider and/or member of the patient's healthcare team discusses with the patient the recommendation for lifestyle and behavioral change to better manage their chronic disease and suggests connection to outside resources for three categories for improvement: physical activity, healthier eating, and chronic disease self-management skills.
  2. Referral - With the patient's consent, a designated person from the care team completes a referral form that has the patient's contact information, basic demographics, and insurance data, along with the selected categories of wellness programs, and transmits this referral electronically (via fax) to the call center that keeps updated and detailed lists of participating community programs and resources.
  3. Outreach and Resource Connection - Once the referral is received, an agent from the WRC call center calls the participant and discusses their best options for participation in community programs taking into consideration interest, location, time, transportation, language, and childcare needs.
  4. Registration - The agent registers the participant for the referred classes/activities and discusses the preferred method of contact for reminders before each activity (phone, email, text messaging). After the patient registers, the WRC sends them a letter thanking them for registering, reminds them of the class they signed up for, and provides information about other classes that they might be interested in for the future. Registration information is emailed to the organization conducting the community class.
  5. Participation & Follow-Up - community programs share participation rates with the WRC. Upon completion of the activity the WRC agent contacts the participant for feedback about their experience, and to sign them up for additional classes. Then the WRC forwards the participation information back to the referring provider via secure email, and reports back aggregated data about the clinic's referrals each month in 'virtual huddles', conference call meetings between the WRC and all clinics. The WRC staff also determine whether or not the participant is eligible for the incentive program. Participants with 80% participation in the series of classes are eligible for incentive drawings. Clinics and providers also have 'anytime' access to their patients' information and an aggregated program dashboard via a secure online portal to the cloud based data management software, Salesforce.

Other Key Requirements

Clinic managers, provider champions, care teams with capacity for referral and counseling. Flexibility, open communication, and commitment to open sharing needs and feedback.


Partnerships between community clinics and the Wellness Referral Center are needed to refer patients successfully. These partnerships include local Federally Qualified Health Centers, Primary Care clinics with the two largest healthcare providers in the area - The University of New Mexico and Presbyterian Healthcare Services, and other community clinics. Partnerships between the referral center and community programs that offer free classes are important to ensure resources to refer patients to. Some of these partnerships include relationships with the local extension agency, the Department of Health, city and county recreation programs, local community colleges, the National Dance Institute, health clinics that provide wellness activities like cooking classes and walking groups, Prescription Trails, and more. Partnerships also exist with funders like Presbyterian Healthcare Services who subsidize some community programs so that they are able to offer classes for free.

Policies, Laws and Regulations

  • Hanging posters or promotional materials advertising the WRC in clinics and hospitals must meet standards (i.e. glossy, or plastic - able to disinfect).
  • HIPPA and HITECH act rules apply.
  • Data sharing agreements recommended.

Required Staffing (FTEs)

Currently, two (2) FTEs are exclusively dedicated to running the Wellness Referral Center. Depending on the scale and whether leveraged resources, there could be at least ten (10) FTEs that primarily support operations of the WRC. These are detailed below. Many other partner organization staff devote small portions of their time to ensuring the continued successful operation of the WRC. Communications and Evaluation are currently contracted out to independent firms.

Special Funding

Some special funding may be required to ensure that resources and classes offered by community programs fit the needs of the target participants and that they are free. This funding has been provided by Presbyterian Healthcare Services community Benefit funding, foundation funds, and special contracts with health insurers for the management of specific populations.

Special Infrastructure

Call Center and/or centralized location to house the referral center.

  • Cloud-based data management software, Salesforce.
  • Call center equipment and computers to access Salesforce for call center employees.
  • Program materials include: referral forms, posters, rack cards, provider toolkits, and instructions.


  • Customer service and program-specific training for call center staff.
  • Data management and analysis training, including Salesforce Software training.
  • Trainings that are needed are specific to how to use the referral center including trainings for clinical staff on referral process and flow.
  • Community programs receive trainings on roles and responsibilities.

Types of Staff

Three (3) Call Center Staff including Call Center Manager. At least one call center operator must speak English and Spanish. Our Data Manager/Senior Software Developer is a certified Salesforce Administrator.

Clinic Connections Coordinator for the WRC; the community Health Manager whose role is to convene stakeholders and partners, build relationships, design and oversee communications, design materials, ensure quality, and serve as a coordinator for the project. Our community health manager specializes in community-clinical linkages and has a Masters's Degree in Communication and nearly 20 years' experience in systems change and improvement. 

Community Health Worker (CHW) at each clinic (optional but recommended) - the role is to explain referral center, programs, responsible for follow up and support of patient goals and progress. CHW's are not required to be licensed or credentialed in New Mexico.

Return on Investment Details

At this time evaluation plans do not include a formal study of the return on investment. Analysis of inpatient utilization and cost may help estimate ROI.

Evaluation Strategies and Data Collection Tools

The Bernalillo County partnership includes the University of New Mexico Prevention Research Center, who formulated the three-year evaluation plan and is currently conducting a process evaluation for implementation of the Wellness Referral Center. Adelante Development Center, Inc., the partner organization that manages the Wellness Referral Center, uses the Salesforce application to store, analyze, and display operations and results of qualitative feedback data on a dashboard. This application provides the opportunity for participating clinics and their care teams to access program participation rates, participant feedback, and other information about the patients they refer in real-time. Additionally, clinics are beginning to automate the storing of referral and participation information into their EMRs. In at least one system, emails with referrals and participation information are stored digitally in a patient's records as a searchable 'order.'.

Process Measures

Key outcome measures relate to:

  • Behavior change
  • Disease outcome improvement
  • Quality of life
  • Sustained clinical and community integration.
  • Increased daily consumption of fruits and vegetables (measured by a survey for specific, community-based programs)
  • Increased consumption of healthy, home-cooked meals (
  • Increased use of fitness classes, community resources for physical activity, walking trails (participation data)
  • Increased self-management of chronic diseases (participation data, clinical data, system-wide population health metrics -inpatient utilization and cost, qualitative data collection
  • Increased quality of life (500 cities BRFSS data, 100 Million Healthier Lives survey, qualitative data collection)
  • Decreased prevalence of chronic disease by census tract, city (500 cities BRFSS data)
  • Decreased death rates due to diabetes by small area, county (vital records data)
  • Long-term, integrated use of referral and clinical care team supports

Program Theory Documents

Key process measures relate to capacity and infrastructure for operations of the intervention, including within referring clinics, within the partner organization running operations of the Wellness Referral Center, and in the community to provide resources that are effective and meet the needs of participants.

The measures below help assess these aspects:

  • Cross-agency trainings to increase awareness and use of Prescription "Rx" for Wellness
  • Cross-agency trainings to improve community health worker skill and referral ability.
  • Increased capacity to deliver diabetes and nutrition education in clinic and community settings, measured by the increase in referrals to these programs over time
  • Demand for and new classes offered in clinics or community centers. The number of new staff hired to deliver or facilitate referrals to these programs in clinics.
  • Increased integration of local food web and healthcare settings, measured by increased referrals to community food resources
  • Demand for healthy food resources (such as clinic food pharmacies, Healthy food pantries, fruit and vegetable referral programs, clinic vouchers for free or discounted food at farmer's markets, etc.)
  • Participation rates.
  • Increased Spanish language health education materials available to educators, clinics, and community settings. Progress is measured by demand for classes taught in Spanish, demand for and use of translated materials, and the number of new multilingual staff hired.
  • The number of community clinics primarily serving neighborhoods and priority populations experiencing greater disparities in chronic disease utilizing the Wellness Referral Center Number of primary providers and care teams referring patients to the Wellness Referral Center. The Number and type of community resources, demand for resources (registrations by type and waiting lists)
  • The number of patients utilizing resources they are connected to via the Wellness Referral Center and participating in cooking classes, Chronic Disease Self-Management programs, walking trails, dance classes, and other lifestyle change activities.
  • The number of patients successfully completing a series of classes, and 'self-referrals' which are friends or family members that accompany the original patient. The number of patients who sign-up for additional community resources after completing the initial referral. Quality improvement and program improvement via feedback from patients who participate or don't participate.

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