Skip to main content
Sister Publication Links
  • ESG: THE NEW IMPERATIVE
Subscribe
  • My Account
  • Login
  • Subscribe
  • News
    • Current News
    • COVID-19
    • Providers
    • Insurance
    • Government
    • Finance
    • Technology
    • Safety & Quality
    • Transformation
    • People
    • Regional News
    • Digital Edition (Web Version)
    • Patients
    • Operations
    • Care Delivery
    • Payment
    • Midwest
    • Northeast
    • South
    • West
  • Digital Health
  • Insights
    • ACA 10 Years After
    • Best Practices
    • Special Reports
    • Innovations
  • Data/Lists
    • Rankings/Lists
    • Interactive Databases
    • Data Points
  • Opinion
    • Bold Moves
    • Breaking Bias
    • Commentaries
    • Letters
    • Vital Signs Blog
    • From the Editor
  • Awards
    • Nominate/Eligibility
    • 100 Most Influential People
    • 50 Most Influential Clinical Executives
    • Best Places to Work in Healthcare
    • Excellence in Governance
    • Health Care Hall of Fame
    • Healthcare Marketing Impact Awards
    • Top 25 Emerging Leaders
    • Top 25 Innovators
    • Diversity in Healthcare
    • Women in Healthcare
    • - Luminaries
    • - Top 25 Diversity Leaders
    • - Leaders to Watch
    • - Luminaries
    • - Top 25 Women Leaders
    • - Women to Watch
  • Events
    • Conferences
    • Galas
    • Virtual Briefings
    • Webinars
    • Custom Media Event: ESG Summit
    • Transformation Summit
    • Women Leaders in Healthcare Conference
    • Social Determinants of Health Symposium
    • Leadership Symposium
    • Health Care Hall of Fame Gala
    • Top 25 Women Leaders Gala
    • Best Places to Work Awards Gala
    • Top 25 Diversity Leaders Gala
    • - Hospital of the Future
    • - Value Based Care
    • - Supply Chain Revenue Cycle
    • - Hospital at Home
    • - Workplace of the Future
    • - Strategic Marketing
    • - Virtual Health
  • Listen
    • Podcast - Beyond the Byline
    • Sponsored Podcast - Healthcare Insider
    • Video Series - The Check Up
    • Sponsored Video Series - One on One
  • MORE +
    • Advertise
    • Media Kit
    • Newsletters
    • Jobs
    • People on the Move
    • Reprints & Licensing
MENU
Breadcrumb
  1. Home
  2. Opinion
February 13, 2021 01:00 AM

We need a better social care referral loop, but it requires technology as well as the human touch

Michele Horan
  • Tweet
  • Share
  • Share
  • Email
  • More
    Reprints Print

    Michele Horan is a registered nurse and senior director of operations at Alliance for Better Health, based in Troy, N.Y.

    As we implement new technologies and gather more data on social determinants of health, it’s critical that we right a pervasive wrong when it comes to meeting social needs: closing the referral loop.

    Imagine, for example, Mrs. Smith comes into the emergency room and is identified as food insecure. A social worker refers her to a local food shelter, but no one follows up and she never receives care. I’ve seen this disconnect in the referral process countless times in my 30 years in the healthcare industry. It perpetuates a heavy burden on individuals who, in addition to food insecurity, may already be facing difficulties like homelessness or mental illness.

    As COVID-19 exacerbates social needs—particularly among underserved communities and people of color—there is renewed urgency to bridge these gaps. We must embrace emerging technologies to streamline our referral systems, but the human touch of providers will remain essential to improving health at scale. 

    Care and continuity
    The most successful referral networks break down the silos of care coordination by digitally connecting medical, behavioral and social care providers. This creates transparency, enables more real-time, informed referrals, and takes the burden off individuals.

    For example, we often find that community members have multiple social needs, and many have a history working with community-based organizations they trust. Think back to Mrs. Smith; imagine if her ER doctor was using a digital system that could see her referral history and notify the same organization she’s worked with before: “Mrs. Smith, I see Catholic Charities provided you food services in the past. Did you know they also provide mental health support?” By improving referral continuity, we increase the likelihood that individuals will actually receive care. 

    It’s important that providers, clinicians and health systems see the value in the real-time knowledge and coordination made possible by these digital platforms. Gone are the days of searching for service information in outdated print directories or calling multiple community organizations to check in on their capacity to assist an individual. Until recently, it was nearly impossible to determine not only whether a referral was made, but also whether or not the community member actually received services. 

    Embracing these tools can improve time management and work flows as much as it can improve health. With adequate training, these tools give providers more time to talk to their patients, assess the underlying basic needs impacting their health, and craft personalized care plans based on where each individual is at in the referral process. 

    Data needed to define success
    When I first started at Alliance for Better Health, I noticed a disconnect in our data: our service episodes were growing, but it was unclear whether the community member was connected, or whether the partner forgot to close the encounter. We had to go back through the unresolved episodes to make sure we addressed the issues that were preventing referrals from resulting in services. 

    Long-term, the growth and success of a referral network comes down to the accurate gathering and analysis of data. Sending 100 referrals each month is great activity, but if 65% of those referrals didn’t ultimately connect people to the services they need, that’s not success. This is where human thinking must step in: What is the reason for the disconnect? Was it a lack of contact information? Or an oversight in data entry? Providers, clinicians, and community organizations can help spot these disconnects, troubleshoot issues, and shape future iterations of the platform to better serve their needs.

    Of course technology is not a silver bullet. While it is incredibly valuable to aggregate the data, the human intervention to monitor it, connect with partners about it, and make improvements based on those insights is truly the root of a network’s success. Digital platforms alone can’t move the needle on health. Each network is only as good as the providers that use it. Let’s make a proactive effort to keep social needs top of mind and embed the social care referral loop into our day-to-day workflows and interaction across the healthcare system.

    Letter
    to the
    Editor

    Send us a letter

    Have an opinion about this story? Click here to submit a Letter to the Editor, and we may publish it in print.

    Recommended for You
    The Check Up: Michael Dandorph of Tufts Medicine
    The Check Up: Michael Dandorph of Tufts Medicine
    covid-and-hospital_i.png
    To report or not to report? CMS COVID quality plan prompts questions
    Sponsored Content
    Get Newsletters

    Sign up for enewsletters and alerts to receive breaking news and in-depth coverage of healthcare events and trends, as they happen, right to your inbox.

    Subscribe Today
    MH Magazine Cover

    MH magazine offers content that sheds light on healthcare leaders’ complex choices and touch points—from strategy, governance, leadership development and finance to operations, clinical care, and marketing.

    Subscribe
    Connect with Us
    • LinkedIn
    • Twitter
    • Facebook
    • RSS

    Our Mission

    Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data.

    Contact Us

    (877) 812-1581

    Email us

     

    Resources
    • Contact Us
    • Advertise with Us
    • Ad Choices Ad Choices
    • Sitemap
    Editorial Dept
    • Submission Guidelines
    • Code of Ethics
    • Awards
    • About Us
    Legal
    • Terms and Conditions
    • Privacy Policy
    • Privacy Request
    Modern Healthcare
    Copyright © 1996-2022. Crain Communications, Inc. All Rights Reserved.
    • News
      • Current News
      • COVID-19
      • Providers
      • Insurance
      • Government
      • Finance
      • Technology
      • Safety & Quality
      • Transformation
        • Patients
        • Operations
        • Care Delivery
        • Payment
      • People
      • Regional News
        • Midwest
        • Northeast
        • South
        • West
      • Digital Edition (Web Version)
    • Digital Health
    • Insights
      • ACA 10 Years After
      • Best Practices
      • Special Reports
      • Innovations
    • Data/Lists
      • Rankings/Lists
      • Interactive Databases
      • Data Points
    • Opinion
      • Bold Moves
      • Breaking Bias
      • Commentaries
      • Letters
      • Vital Signs Blog
      • From the Editor
    • Awards
      • Nominate/Eligibility
      • 100 Most Influential People
      • 50 Most Influential Clinical Executives
      • Best Places to Work in Healthcare
      • Excellence in Governance
      • Health Care Hall of Fame
      • Healthcare Marketing Impact Awards
      • Top 25 Emerging Leaders
      • Top 25 Innovators
      • Diversity in Healthcare
        • - Luminaries
        • - Top 25 Diversity Leaders
        • - Leaders to Watch
      • Women in Healthcare
        • - Luminaries
        • - Top 25 Women Leaders
        • - Women to Watch
    • Events
      • Conferences
        • Transformation Summit
        • Women Leaders in Healthcare Conference
        • Social Determinants of Health Symposium
        • Leadership Symposium
      • Galas
        • Health Care Hall of Fame Gala
        • Top 25 Women Leaders Gala
        • Best Places to Work Awards Gala
        • Top 25 Diversity Leaders Gala
      • Virtual Briefings
        • - Hospital of the Future
        • - Value Based Care
        • - Supply Chain Revenue Cycle
        • - Hospital at Home
        • - Workplace of the Future
        • - Strategic Marketing
        • - Virtual Health
      • Webinars
      • Custom Media Event: ESG Summit
    • Listen
      • Podcast - Beyond the Byline
      • Sponsored Podcast - Healthcare Insider
      • Video Series - The Check Up
      • Sponsored Video Series - One on One
    • MORE +
      • Advertise
      • Media Kit
      • Newsletters
      • Jobs
      • People on the Move
      • Reprints & Licensing