Closed Loop Referral CARE Network.
Project Overview
This project advances the development, implementation, and evaluation of a regional closed-loop referral infrastructure that links healthcare and social service organizations to improve care coordination for non-medical drivers of health in Greater Houston. It strengthens governance, technology, organizational capacity, and sustainability planning while establishing an evaluation framework to measure efficiency, effectiveness, and long-term impact.
Project Details:
Social determinants of health outcomes such as food insecurity are root causes of health inequities. Healthcare organizations seek to address these factors by referring patients to social and community services. However, the lack of referral tracking across organizations doesn’t allow the healthcare provider to support their patients effectively. According to recent data, up to 50% of referrals are not completed, and a recent analysis of food prescription programs in our region had similar rates of incomplete referrals.
The commitment of UTHealth Houston and the Coalition of Connected Care is to facilitate the development of governance and technology capacity for a bi-directional closed-loop referral infrastructure and improve community resource accessibility. This closed-loop referral will allow multiple organizations (healthcare and community-based organizations (CBOs)) with varied technologies to refer patients/clients for social services they need.
Linking health care organizations can community organization hubs via Greater Houston Healthconnect (GHH), our regional health information exchange (HIE). GHH that currently services nearly all of healthcare organizations in our region and has a master patient index of over 20 million.
The potential impact of this demonstration project is significant and our closed-loop referral infrastructure will:
(1) facilitate closed-loop referral for care coordination between social service agencies and health care institutions to improve access to services to mitigate SDOH needs, including food insecurity.
(2) develop the ability to analyze and evaluate data to determine care coordination and programmatic effectiveness and unmet needs, leveraging national data standards.
(3) establish accountability and good governance for all of the above by centering the perspectives and needs of providers and clients.
(5) advance adoption and sustainability model for continuation of these efforts.
This demonstration project is positioned for rapid scaling by linking existing care coordination hubs across healthcare providers and social services.
Project Contact: Heidi Hagen McPherson, MPH
Project Team
Principal Investigator
Shreela Sharma, PhD, RDN, LD
Director, Center for Healthy Communities
Professor and Vice Chair, Department of Epidemiology
Sr. Project Manager
Heidi Hagen McPherson, MPH
Co-Lead, Coalition of Connected Care
Co-Investigator
Micaela Sandoval, PhD
Assistant Professor, Department of Epidemiology
Co-Investigator
Jose Miguel Yamal, PhD
Professor, Department of Biostatistics
Data Manager
Michael Gonzalez
Center for Healthy Communities