Improving Patient Referrals: PHC and Iowa Community HUB Wrap Up National Design Sprint

PHC Collaborates on National Project to Improve Patient Referrals and Education

Primary Health Care (PHC) recently completed a five-month Design Sprint with the Iowa Community HUB and the National Association of Community Health Centers (NACHC). This collaborative project focused on improving the screening and referral process for patients with osteoarthritis of the hip and knee—conditions that affect many in our communities.

Representing PHC on the project were Teresa Fisher, RN, Nurse Care Manager, and Lashelle Goode, ARNP, both based in Ames. Teresa and Iowa Community HUB’s Rachelle Scott Oakley wrapped up the project by presenting their work during a national celebration and share-out event held in Bethesda, Maryland.

The challenge they tackled?

Simplifying the referral process. Right now, too many clicks and delays in the screening workflow make it harder for providers to follow through on community resource referrals.

The team tested two key solutions:

• Increasing provider support through the Nurse Care Manager role.
• Creating clear, patient-friendly education about the Iowa Community HUB and the programs it offers.

By focusing on osteoarthritis care, the group aimed to help patients access evidence-based programs that improve quality of life, including exercise, nutrition, and wellness resources available through the HUB.

Throughout the Design Sprint, the team used data, gathered feedback, refined their tools, and strengthened their partnerships. The outcome? A more streamlined, patient-centered referral process—and stronger collaboration across community-based care teams.