Closed Loop Referral demonstration project: building the technology to improve health outcomes

By Shreela Sharma, PhD, RDN, LD

Screening for non-medical drivers of health has been mandated by hospital systems nationwide. These non-medical drivers of health (NMDOH), such as lack of food, housing, transportation, and access to care, contribute to poor health outcomes in the US.⁽¹⁾ The Health Equity Collective (HEC), a systems coalition in the Greater Houston region consisting of over 300 organizations with a singular purpose of improving care coordination for NMDOH across sectors using a collective impact approach⁽²⁾. The Center for Health Equity serves as the backbone organization of the Health Equity Collective and is co-led by Shreela Sharma, PhD, and Heidi McPherson, MPH. 

Success of addressing NMDOH needs for communities hinges on successful care coordination between healthcare and community-based organizations (CBOs) so patients can receive the services needed seamlessly. Despite these social/community service programs gaining popularity, there is currently no standardized national system for health care providers to make or track referrals systematically to “close the loop” (i.e., bidirectional information sharing and communication between practices, including making referral requests to specific agencies, and timely and clear communication response regarding the referral).2 The lack of systematic referral tracking has resulted in patients not receiving the social services needed to manage health conditions and maintain health.  The HEC is facilitating the build of a technology-based closed loop referral infrastructure such that health systems can seamlessly refer to CBOs for NMDOH needs.  This closed-loop referral infrastructure creates a bidirectional flow between healthcare and CBOs to refer their patients in need to receive NMDOH services needed. As part of this effort, the HEC is leveraging the local health information exchange with a master patient index of over 18 million records, as well as sector-specific regional care coordination platforms, health systems and community organizations to build closed-loop referral capacity between HIE-participating health care organizations and community organizations to meet patient NMDOH needs.   

Evaluation efforts will assess the reach, adoption, implementation, and the effectiveness of the closed-loop framework in improving social and health outcomes. The framework comprised the following four components: (1) establishment of collaborative governance for shared decision-making processes, fostering trust, alignment, and transparency among organizations; (2) development of technology linkages between existing platforms to facilitate seamless referrals between organizations and ensure visibility of referral outcomes; (3) integration of regional resource directories into technology infrastructure to ensure resource accessibility/quality; and (4) evaluation of the system’s impact on health equity, efficiency, and cost reduction. 

This project aims to close the loop for care coordination between health care and CBOs, enable data evaluation to determine care coordination effectiveness, and lay the foundation for NMDOH-related research/practice equitably. 

To read the full publication detailing the design and framework of the CLR in Population Health Management, click here.  

1. Braveman P, Gottlieb L. The social determinants of health: it's time to consider the causes of the causes. Public Health Rep. 2014;129 Suppl 2(Suppl 2):19-31.
2. Kania J, Kramer M. Collective Impact: Stanford University; 2011 [Available from: https://ssir.org/articles/entry/collective_impact.