Screening, Testing and Referral

Screening, testing and referral is when primary care physicians and healthcare teams screen and test patients that may have risk factors for chronic disease and refer them to the appropriate clinical or community resources. 

What is Screening, Testing and Referral?

Detecting and Treating Chronic Disease

The screening, testing and referral (STR) strategy can be used as an effective strategy in prevention to detect and treat chronic disease. However, most patients are not identified as high risk in the early stages. Utilizing the screening, testing and referral strategy can help identify at-risk patients in need of additional healthcare to help monitor their conditions. Referrals from healthcare providers can be an important predictor of enrollment in evidence-based prevention and management programs such as the National Diabetes Prevention Program and Diabetes Self-Management Education and Support program.

Implementing the screening, testing and referral strategy at your healthcare facility:

  • Save time during office visits
  • Decrease costs and secures savings
  • Improve health outcomes
  • Increase quality measures
  • Decrease patient population risk for chronic diseases

Effective Screening and Testing

Healthcare providers can identify target populations by risk, level of engagement or target conditions, for example: 

  • Those with elevated blood pressure and other major risk factors (such as obesity, cardiovascular disease, tobacco use, or socio-demographic risk factors that, if identified and counseled, may assist in reducing the risk of disease)
  • Those with potential prediabetes or diagnosed diabetes who have not had a visit in more than 1 year
  • Those with potential prediabetes or diagnosed diabetes with uncontrolled blood sugars at two separate medical visits during a defined period
  • Active or Inactive patients 


Extracting electronic health records (EHRs) can help support healthcare providers using EHRs to screen for, diagnose and manage prediabetes and diabetes on patients who meet criteria.

  • Adopt algorithm(s)
  • Convert algorithm into data extraction report (for pulling patient lists); and/or
  • Create an EHR Alert/Flag (for use at point-of-care)
  • Develop process for ongoing data extraction and pre-visit identification of patients who meet criteria


When using the screening, testing and referral strategy, implement best practices like team huddles and panel management for detecting, treating and partnering with patients to prevent the progression of their chronic disease(s). This is a proactive way to ensure that everyone assigned to a clinic is up to date on basic preventive care – like screenings or immunizations – and that the patient receive extra help if they have lab numbers that are high. Panel management can be used as a proactive mechanism where clinical staff members identify at-risk patients and notify them about healthcare plans they didn’t know was needed to prevent or manage their conditions. Outreach panel management can be defined as clinical staff members who reach out through phone or letter to a patient who does not have an upcoming appointment or has not been seen at the clinic recently. Clinical staff members can also notify patients about healthcare gaps while they are in the clinic receiving care for other issues in a process known as in reach panel management.

High Quality Referrals

High quality referrals are bidirectional—a system which considers both the information going from the healthcare system to the referred community program or resource—and help to close the healthcare gap by providing real-time updates to the referring healthcare provider on the patient’s status. Implementing a defined referral process will help the patient successfully access the referred lifestyle change program. Creating a referral system with community resources can make it easier for community organizations to loop back around to the referring healthcare provider, thus forming a community-clinical linkage

Find a Lifestyle Change Program Near You!

Use our search tool to find community resources and programs you can refer your at-risk patients to and help them prevent or manage their chronic conditions.

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