Public health nurses make and receive referrals. They may send or initiate a referral on behalf of a client or may receive a referral for a new or already known client. The process of
receiving referrals at a public health nursing organization is generally formal to accommodate the frequency of requests and to provide a means to track data and referral outcomes. Referrals—both formal referrals from organizations and professionals and informal referrals from the client or the client’s network—are received as part of an intake process at the public health nurse organization. In some agencies, public health nurses are permanently assigned to receive referrals, and in some agencies the intake function rotates among nurses. For cost or effectiveness reasons, intake may be alternatively delegated to skilled non-nurse staff members under the direction of a public health nurse. Once a referral is received, it is weighed and a plan to respond is established. The referral may be accepted for services from the public health nurse organization, or it may be determined that the needed resources or services are not available from the public health nurse organization. In this situation, the referral may be declined and the referring agency or person promptly notified by intake public health nurses.

The intake public health nurse may also make recommendations for more appropriate, alternate agencies to receive the referral. Most communities have organized systems of information and referral, generally directed by social workers educated in this specialty area. Contacts with information and referral systems, sometimes called “First Call for Help,” are available by telephone and increasingly online for specific geographic communities. Many states now have a “211” switchboard to connect callers to community resources. These systems request specific information about the client and the need to closely match the request with an appropriate resource. Information and referral differs from the public health nurse intervention of referral and follow-up in that information and referral provides only information on available resources. Even though information and referral agencies may provide comprehensive information, information and referral does not make a referral or conduct follow-up. Based on information provided by the information and referral agency, the public health nurse or the group/family must select a possible resource and contact the suggested service agency to initiate a request for assistance.

It is important to note that the intake function of public health nurse agencies provides nurses and organizations with information about community needs and about gaps in resource availability, affordability, and appropriateness. Even when a public health nurse organization is unable to respond to an intake request, each request helps build a description of current community needs. When a mismatch between community need and existing resources is found, public health nurses and public health nurse organizations will seek to meet emerging or newly defined needs by developing new resources or by modifying or improving existing resources. Analysis of the needs may also suggest that resources exist but that there is a barrier to access. For example, a community organization providing HIV/AIDS prevention and care services has historically targeted a defined geographic area. Now, a neighboring area requires resources because it has experienced increased HIV incidence and AIDS prevalence. One solution would be to expand the existing HIV/AIDS service area into the neighboring community.

Public health nurses must gain a working knowledge of available community resources to make effective referrals and must develop working relationships with resource organizations to fulfill follow-up obligations. How does a public health nurse build knowledge of community
agencies and resources? Descriptive and contact information about community agencies and resources should be included in the public health agency orientation and public health staff development programs. Information can be shared in print or electronic formats, especially when there are changes in eligibility or availability of services. Many public health nurses maintain contact lists or active files of potential community resources. Public health nurse agencies may also develop relationships with specific resources, which may include formal strategies for interagency contact, referral, and follow-up (Allender & Spradley, 2005). Consultations with public health nurse supervisors or agency social workers can assist public health nurses to identify relevant resources.

In addition to formal structures for gaining information about community agencies, organizations, and resources, public health nurses learn about agencies through their informal networks. Informal networking with other public health nurses is often the most fruitful source of resource identification. Clients, families, and other health professionals can provide information about resources, which is especially helpful when it is from the resource user’s viewpoint. Observing the presence and activities of other agencies and organizations in a community also suggests who is operating in an area and the types of services offered. For example, home-delivered meals are a strategic service for homebound elders and the chronically ill. Before referring a client, a public health nurse would pose questions about the service to colleagues and clients. Perhaps a home-delivered meal program provides excellent meals at the promised time at an inexpensive cost. On the other hand, perhaps the service’s waiting list is 10 months, meals are too salty for many recipients, and delivery drivers get lost and miss deliveries. Knowing what to expect from a potential resource, as well as whether the client can accept the pros and cons of resource operations, enables the public health nurse to weigh the value of the actual referral.

A referral must have merit. “Merit” takes into consideration whether a referral is the right referral at the right time for the right client. Determining the merit of a referral is heavily influenced by community values and expectations and (1) whether or not referrals are an effective strategy, (2) the timing of a referral, (3) whether the referral is to prevent a problem or address an existing problem, and (4) the nature of the “match” between the referral resource and the client.

Among public health nurses in some agencies, developing and making referrals is an infrequent activity. Client needs may have been overlooked, resources are scanty, or the nurses are overwhelmed. On the other hand, most public health nurses would agree that use of community resources extends the effectiveness and quality of public health nurse interventions and is well worth the time and attention required to prepare and complete a referral.

The actual timing of making referrals may vary among public health nurses and across public health nurse organizations. Some public health nurses wrap referrals into case closure activities, whereas others ensure that referrals are made early enough in the nurse—client relationship that new community resources have begun client services before public health nurse service termination; this makes it easier to conduct follow-up activities as the nurse maintains contact with the client before case closure. The public health nurse can both observe the impact of the community resource’s contacts with the client and directly ask the client about the use and success of the referral agency’s services.

Public health nursing approaches also vary in whether community resources are applied early to prevent client crises or in a more targeted fashion to address client crises once present. Many public health nurses prefer to engage in preventive activities to avoid crises, although some would rather reserve community resources to address emergent problems. Both perspectives are based in ethical judgments about when and how services are best involved, and both raise questions about cost-effectiveness. In prevention, lower cost can be spread over a wider population whose members may or may not be at risk. Public health nurses often base interventions on the ethic that suffering should be prevented whenever possible. When addressing crises that have already occurred, individual costs are likely higher, but these costs are directed only at individuals experiencing actual health problems.

Some client groups are seen as more deserving than others of receiving resources. Some clients can be viewed in a more favorable light than other clients, because their concerns or needs are interpreted in a more sympathetic manner. For example, a person with alcoholism, living on the street, might be viewed less sympathetically than a stable couple with a young child. Or those making every effort to improve their health would be viewed more positively than those with the same health concern but who make no effort to help themselves. Society is more willing to provide aid and assistance when clients are sympathetic, are deemed “moral,” and are seen as attempting self-improvement. When the public views a client group as being more “deserving,” they are willing to provide greater resources for resolving their needs and are more open to paying for more expensive resources (Dieckmann, 1999; Katz, 1996). For example, as AIDS has become more mainstream since the mid-1980s, communities are more willing to commit resources to people living with HIV/ AIDS. When clients are viewed as sympathetic and deserving, it is more acceptable to fund services and more resources become available. These principles not only have implications for individual/family use of referral resources but also for the overall availability of resources at the community and systems practice levels.

Implementing the steps of the referral and follow-up intervention assumes active client participation and client control. Assistance in planning is offered to the client, and the public health nurse collaborates with the client. Because the referral process is client-centered, the public health nurse avoids making decisions for the client but seeks to establish a working partnership that uses a problem-solving approach to achieve shared goals.

Individual/family clients, populations, communities, and systems vary across a continuum as to their ability to contribute to the referral process. Some clients are dependent on the public health nurse for gathering information, weighing options, and requesting the referral. In these situations, public health nurses use referral planning and implementation to build relevant skills and independence in clients. Other clients are more independent in considering and implementing referrals, placing the public health nurse in almost a consultative role. Here, the public health nurse validates and extends these clients’ independent problemsolving behaviors. The public health nurse provides clients with the opportunity to learn and adopt new behaviors to achieve their next steps to full independence.

The steps to conduct referral and follow-up are sequential; these steps are based on the outline provided by Clemen-Stone and colleagues
(2002) and McGuire, Gerber, and Clemen-Stone (1996). If a need or resource cannot be identified or if the client declines referral, it may be useful to revisit earlier steps. These steps are appropriate for individuals/families, populations, communities, and systems. Additional comments about the implications of the referral and follow-up intervention for communities and systems are found at the end of this section (see Referrals and Follow-Up at Systems and Community Practice Levels, below).

Step 1: Establish a Nursing Relationship With the Client. Nursing interventions begin with establishing a respectful working relationship with the client, which serves as a basis for individualizing or targeting care. The referral and follow-up intervention is often used with existing clients for whom the public health nurse has provided other public health interventions. Here, the professional relationship has already been established. On the other hand, a public health nurse may initiate a professional relationship with a new client solely to develop and implement a referral and follow-up. Whether based in an ongoing collaborative intervention or in a brief encounter, the public health nurse must similarly establish trust and gain the client’s agreement to engage in the referral process. Public health nurses may quickly assess and develop working hypotheses about the client that may later be confirmed, but the nurse should not establish fixed assumptions in the initial step.

Step 2: Identify Client Need and Set Objectives for Referral. Based on a caring, professional relationship with the client, the public health nurse gathers information about the client and the client’s context. Listening to the client’s perspective on his or her current situation and larger context is crucial (Wolfe, 1962). What is the client’s need and what are the parameters of the need? Clients may benefit from a thorough discussion of the need. Allowing the client to review and describe a need provides essential information for the nurse, but the process of verbally articulating needs also enhances client comprehension of the need, investment in the referral process, and self-efficacy in securing a solution. Because one intention of the referral process is to increase client independence, incorporating strategies that facilitate client empowerment are beneficial to strengthening current decisions for self-care and later self-determination.

When the public health nurse has secured an apparent understanding of the client’s needs, the nurse reflects a synthesis of the need back to the client to confirm that what has been heard is what the client meant to convey. Probing for further client information or perspective may be helpful. After brief consideration, the public health nurse presents his or her summary of the client’s expressed need and proposes options for addressing this need. Critically important at this point is the nurse’s determination whether the client’s need is in practice one need or several. If several, then the public health nurse proposes at least two ways of posing the need and gains client agreement with one interpretive approach. Given a favored approach, the nurse and client work collaboratively to establish objectives for the referral.

This give-and-take process may be quite brief, or it may be lengthy. If the referral and follow-up intervention is
conducted with an individual/family, organization, community, or system, more than one well-organized meeting may be required to share information, make decisions, and gain a working consensus about objectives. As the process of making a referral proceeds, the nurse and client may choose to return to this step for further clarification of need(s) and redetermination of objectives.

Step 3: Search for Resources and Explore Resource Availability. A systematic search for resources to meet the need and the identified referral objectives is conducted by the nurse, sometimes with participation of the client. Public health nurses familiar with meeting needs similar to the client’s may quickly establish a group of options, either from personal experience or from consulting personal or agency resource files. Addressing more complex client needs may require consultation with professional colleagues or with information and referral specialists. Although the principles of making a good referral can guide the public health nurse, a nurse’s experience and confidence in making referrals contributes to a prompt and personalized outcome. A nurse’s ability to apply the art of nursing is especially relevant in the selection of potential referral resources. The client and the resource must fit together in both tangible and intangible ways for the referral to effectively accomplish the identified goals.

Step 4: Client Decides Whether to Agree to Referral. Information about potential referral resources is presented and discussed with the client. The client may select a resource(s), may wish to consider the resource(s), or may decline to agree to any referral. It can be helpful to provide clients with written information to allow later review of potential resources or later communication with the resource by the client. Application of the referral and follow-up intervention is based on ethical principles of client self-determination that places decision making in the hands of the client (McGuire et al., 1996). When a client is uncertain or declines referral, the public health nurse may explore the client’s feelings and reasons, identify factors that might facilitate or deter resource use, negotiate use of identified resources, propose a wider variety of referral resources, and/or reassess the client’s needs and objectives for service. If a client declines referral at any point, no referral is made. The nurse must balance encouragement with an open ear that the client does not wish a referral.

Step 5: Public Health Nurse Matches Client With Resource and Makes the Referral to the Resource. The client and the nurse select a resource or resources that best match the client’s needs and preferences. Does the client believe the resource will work for him or her? The public health nurse’s knowledge of the client and client’s needs is important in making the referral to the identified resource and in explaining the client to the agency. If the client is a population, community, or a system, a referral might be a grant application or similar application to secure program funding. When clients are more experienced or skilled, they may make the referral themselves; this increased skill in self-managing care is a factor in client empowerment. Other clients may lack experience, be self-doubting, or be overwhelmed and emotionally fragile. As the nurse makes
the referral, he or she asks questions and gains more information to assist the client to maximize interactions with the resource. The public health nurse also provides the client with tailored information about the resource and with anticipatory guidance on using the agency’s resources.

Some agencies require detailed application information; the nurse gathers information and confirms with the client what information should be shared. Some communities use written interagency referral forms that have been developed to address system and resource needs for sharing information. Although patient privacy laws now prevent their use, in the past the agency that received a written referral would respond in writing to the referral source to describe initial contacts and plans for the referred individual or family (Cady, 1952; Kraus, 1944).

Step 6: Follow-Up to Facilitate Client Utilization of Resource. Nursing interventions at this step, alternatively called “following along,” can ease the client’s experience with the resource. Soon after the client follows through and contacts the resource, the public health nurse contacts the client to determine the client’s progress and engagement with the resource. Is the client using the resource as planned? Is the resource agency engaged with the client? The public health nurse can reemphasize the purpose of the referral, interpret the resource to the client and the client to the resource, and promote linkages between client and resource. If signs of a weak linkage are found, the nurse may advocate for the client with the resource. The public health nurse can also directly address any barriers to seeking or using the resource (Will, 1977).

Step 7: Evaluation of Referral Process and Outcome, Client Outcome, and Resource Assistance. Did the client receive services and what was provided by the resource? In what ways did the client’s status change as a result of working with the resource? Obtaining adequate information and data for evaluation can be challenging but is an essential element in the ongoing process of making referrals. Whether the client is an individual/family, population, community, or system, evaluation of referral and client outcomes has system-level implications. Lack of resources or poor service from resources in the community suggests gaps that public health nurses should address. Because the referral and follow-up intervention is a continuous process, public health nurses learn from each referral and provide feedback to improve the system itself and nurses’ utilization of system resources.

Successful follow-through on any referral frequently depends on the resources of clients and is based on several factors. Wolfe’s (1962) classic analysis identified the central role of client motivation in initiating resource utilization: To what extent does the client see the referral and resource use as important? Does the referral appear to be practical and relevant to the client’s situation? Individualizing the referral for the client or the family and tailoring the referral to the client’s expressed preferences enhance referral utilization.

The concepts of perceived benefits and perceived barriers in the health belief model can assist in facilitating client follow-through for resource use. Clients accept a recommended referral only when they expect a benefit that is
greater than the perceived barriers. Public health nurse interventions are designed to enhance perceived benefits by clarifying the expected positive impact of accepting the referral and by explaining specific actions to engage with the referral resource. At the same time, public health nurse interventions are directed toward reducing perceived “tangible and psychological costs” of accepting the referral by identifying perceived barriers and reducing their impact through clarifying misinformation and applying reassurance, incentives, and concrete assistance to use the resource (Champion & Skinner, 2008, pp. 47-49). For example, referral follow-through by patients at risk for cancer was improved when diagnostic/treatment appointments were scheduled within 2 weeks, when patients received clear instructions, and when patients received careful attention from the clinic staff (Manfredi, Lacey, & Warnecke, 1990).