Closed Loop Referral Network.
Project Overview
A robust Information Exchange infrastructure leveraging the existing Health Information Exchange (HIE) to coordinate care for multiple social needs of an individual at any given time and allow for healthcare organizations to conduct warm referrals to social service agencies.
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 Health Equity Collective 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.
his effort has garnered national attention and was recently accepted into as one of the 141 White House Challenge to End Hunger and Build Healthy Communities commitments. As a part of this White House effort we are committed to evaluate and scale this effort across the region and beyond.
For More on the White House Challenge Link below:
Project Funders
- Episcopal Health Foundation
- Powell Foundation
- Rockwell Foundation
- Blue Cross Blue Shield of Texas
- Cullen Trust for Health Care
- UTHealth
- Memorial Hermann Benefits Corporation
Project Contact: Heidi Hagen McPherson, MPH
Project Team
Shreela Sharma, PhD, RDN, LD
Co-Lead, Health Equity Collective
Director, Center for Health Equity
Professor and Vice Chair, Department of Epidemiology
Heidi Hagen McPherson, MPH
Co-Lead, Health Equity Collective
Micaela Sandoval, PhD
Assistant Professor, Department of Epidemiology
Sisan Tennyson, MPH
Research Coordinator, Department of Epidemiology