Participant Service Referrals Training

Taking a Systems Approach to Referrals

Senior nutrition programs can improve participant access to services by enhancing 

staff training and developing consistent referral approaches. The tips below can help 

you get started with a systems approach to referrals. 

• Identify and communicate staff and volunteer roles in the referral process to 

ensure everyone understands what steps to take when they encounter a 

participant’s need. In this way, organizations can create a genuine No Wrong 

Door, allowing participants to access services – regardless of whom they ask. 

• Train staff and volunteers to conduct an effective warm handoff. Demonstrate 

the process and provide scripts for reference to enable them to connect 

participants more fully to services. 

• Develop partnerships with other providers in your community that offer

services to your target population and identify the best process for staff and 

volunteers to make a warm handoff.

• Cultivate relationships and develop agreements with organizations that have 

staff trained in resource navigation and/or care coordination, such as the 

Aging and Disability Resource Center, the Center for Independent Living, or 211, 

to help fill the gaps in services and staff/volunteer knowledge. Care 

coordination is a time- and skill-intensive process and should not be 

expected of all staff and volunteers. 

Action Steps

 Create an outline of staff and volunteer roles that can be used as a reference 

for staff members. A workflow diagram will allow staff and volunteers to 

understand their role and with whom to communicate when they identify a 

participant’s need. 
 Convene staff and volunteers to share roles and answer any questions on 

steps that should occur when needs are identified. Use case scenarios and 

role-playing to reinforce the message. 

 Identify community partners that can fill gaps in your agency’s services and 

make a resource list available for all organization members. 

 Ensure organizations know they may receive referrals from your staff or 

volunteers. 

 Acknowledge the limitations of staff roles in identifying issues and making 

service referrals, understanding the intense training and time needed to 

provide full information, referral, and assistance services. 

Staff/Volunteer Training Guide

When preparing for staff and volunteer training, consider which staff should lead and 

which should attend based on your organizational structure and expertise. Be 

prepared with the necessary equipment and supplies, such as internet access and a 

large screen for presentations or screen sharing, a whiteboard or large pads of

paper for documenting brainstorming activities, and notecards for small group 

discussion and sharing. The suggested steps below can guide your training session.

• Review the content below and consider responses you would expect for each 

activity, so you can fill in any blanks during the discussion and ensure the

intended messages are transmitted. 

• Welcome staff and volunteers and share the day’s topic. The language from 

the tip sheet may be used to set the scene. 

• Verbally acknowledge that staff and volunteers:

o Have an important role in the organization.

o Are not case managers or resource specialists and are not expected to 

be.

o Should come to you with any questions or concerns about the agency's 

systems approach for referrals.

• Walk through the Referrals and Interventions for Older Adults with Food 

Insecurity: Webinar Takeaways with the team, focusing on the definition and 

tips around warm handoffs.

• Share your agency’s workflow with your team and identify the relevant roles in 

the process for staff present. 
• Present the following case scenario, which will be used to facilitate discussion 

around the training topic.

Mrs. T. is a new participant at the senior center who attends group dining and 

bingo two days per week. She has spoken with intake staff, participants, and 

activity coordinators about a variety of needs, including a ramp for her front 

door, financial assistance, and help managing her husband’s care. Staff 

members have referred her to services within the agency and through partner 

organizations, but she hasn’t called any of the providers. 

• Discuss the following questions as a group or in small groups, with one 

representative sharing the group’s findings.

o What services may Mrs. T. benefit from that are offered by our 

organization or a partner agency?

o Why may Mrs. T. not be moving forward with the referrals?

o Does the involvement of multiple staff act as a barrier or a facilitator for 

Mrs. T.?

o What steps should staff take in this case, based on our organizational 

flow chart?

o What are the limits of your role in communicating with Mrs. T?

o When and how should you connect to an outside resource navigation or 

care coordinating agency?

• Demonstrate a warm handoff for this case through role-playing, with one staff 

member taking on the role of Mrs. T. and one as the Center’s staff. The role 

players should be prepared and comfortable demonstrating.

• Thank the presenters and engage staff/volunteers in a discussion using the 

following prompts:

o How did Mrs. T. respond to the warm handoff?

o Why may this strategy be more successful than asking Mrs. T to reach 

out without support?

o How do staff or volunteers respond to Mrs. T. if she continues to present 

these needs?

• Share selected resources from the tip sheet and allow staff time to review 

them during work hours.
Resources

• Implementation Quick Start Guide Warm Handoff — Agency for Healthcare 

Research and Quality

• Partnerships with Foodbanks and Other USDA Programs — Nutrition & Aging 

Resource Center

• Aging & Disability Resource Centers — Administration for Community Living

• Referrals & Interventions for Older Adults with Food Insecurity Webinar

(YouTube) —Nutrition and Aging Resource Center

o Referrals & Interventions PowerPoint slides

o Referrals & Interventions Takeaway sheet

• Care Delivery Models That Identify and Address Social Determinants of Health — UNC

• Maryland AAA Malnutrition Pathways Toolkit — Network example of a systems 

approach to referrals