Establishing and Providing Effective Referrals for Clients: A Toolkit for Family Planning Providers

Title X-funded agencies are expected to provide appropriate referrals for medical, informational, educational, and social services related to family planning for clients who want such services.²

Title X grantees, subrecipients, and/or service sites are expected to develop and implement plans to coordinate with and refer clients to other providers of health care and social services, optimally with signed, written collaborative agreements.

Title X agencies should provide for coordination and use of referrals and linkages with, at a minimum: 

• Providers of other health care services not provided on-site (e.g. primary or specialty care such as infertility, infectious disease, prenatal care, pregnancy termination)
• Other medical facilities (including hospitals) when medically indicated
• Infant care, foster care, adoption
• Local health and welfare departments (e.g. SNAP, WIC)
• Voluntary agencies (e.g., domestic violence, crisis intervention, Alcoholics Anonymous)
• Ancillary services which may be necessary to facilitate clinic attendance (e.g. childcare, transportation)
• Health services projects supported by other federal programs, who are in close physical proximity to the Title X site, when feasible, in order to promote access to services and provide a seamless continuum of care.

Title X grantees are expected to have a written policy that requires subrecipients and service sites to have policies for providing needed referrals.

Referrals should be provided when a clinical service provider determines that a client has either medical or social service needs beyond the scope of the clinic’s services. Not all referrals, however, require the same level of support to the client.

Referral-making encompasses a spectrum of potential information-giving and supportive behaviors. These range from providing information on specific services to follow-up on service utilization and outcomes and continuous assessment and improvement of the quality of referrals. “Cold” and “warm” are often used to describe referral behaviors at two points along this spectrum.

A cold referral means providing information to the client about another agency or service, and it is then the client’s responsibility to contact the agency or service (for instance, after receiving a business card or name and phone number for a local resource).

A warm referral involves contacting another agency or service provider on the client’s behalf. This entails calling and making an appointment for the client, providing support to overcome barriers to care, and following up to determine if the appointment has been kept.

Agency policies should indicate the type of referral that is usually most appropriate for each service. Referral type may also depend on the client’s individual circumstances, so providers should use their best judgement.

For more information, see Dobbs v. Jackson Women's Health Organization U.S. Supreme Court Decision: Impact on Title X Program Q&As for Title X Recipients.

Title X agencies should identify other health care and social service agencies serving the same target population to explore whether having an informal or formal relationship may be mutually beneficial. It is important to develop partnerships with community groups, programs, and organizations that represent various sectors and stakeholders, including those addressing social, economic, and environmental factors—the social determinants—that affect sexual and reproductive health.

A memorandum of understanding (MOU) is a written document, generally not legally binding, that outlines a voluntary agreement between parties. It can facilitate inter-agency communication, coordination of services, and continuity of care for clients. A MOU does not need to include complicated legal conditions, exclusions, indemnifications, etc. It should support the work of the collaboration, not inhibit it.

Providing high-quality referrals involves assessing individual clients’ circumstances, identifying potential barriers, and helping them to problem-solve and reduce all barriers, therein increasing their ability to access referral services. Without support, clients may receive referral information, but still not access services. Some of the many barriers Title X clients face in accessing services are related to: 

• Finances
• Language
• Transportation
• Lack of child care
• Age-based consent issues
• Legal and policy
• Fear of a lack of privacy
• Fear of judgement
• Fear of scorn, intimidation, coercion, or threats
• Fear of disclosing immigration status

Ensure staff have adequate training and support to help clients with ways to overcome these barriers so they can access the services they need.

Staff must be prepared to provide appropriate referrals and training, identify roles, and develop processes to ensure consistent implementation. 

Ensure that referrals and associated processes are well-documented. Close the communications loop for high-priority referrals by establishing clear expectations for client-centered communication while respecting client autonomy and confidentiality. Assess periodically how effective agency referrals are and adjust accordingly.

1. Frost JJ, U.S. Women’s Use of Sexual and Reproductive Health Services: Trends, Sources of Care and Factors Associated with Use, 1995–2010, New York: Guttmacher Institute, 2013, https://www.guttmacher.org/report/us-womens-use-sexual-and-reproductive-health-services-trends-sources-care-and-factors, accessed December 7, 2021.
2. Code of Federal Regulations 42 CFR 59.5. https://www.ecfr.gov/current/title-42/chapter-I/subchapter-D/part-59 Accessed December 7, 2021.
3. Title X Statutes, Regulations, and Legislative Mandates. https://opa.hhs.gov/grant-programs/title-x-service-grants/title-x-statutes-regulations-and-legislative-mandates Accessed December 7, 2021.