Connecting the Dots: Referrals between Medical Care and Community Resources

Policymakers and providers all agree that addressing patients’ non-medical needs will be critical to improving health, health care, and health care costs, but little progress has been made towards integrating traditionally segmented services. What can and should a health care organization do? Realistically, most health care organizations will not build new lines of social services into their core clinical operations. Instead, leading organizations are connecting the dots by optimizing referrals to existing community resources. Based on phone interviews and site visits with executive leadership, frontline providers, and community partners, we highlight the work of nine innovative health care organizations. Here, we offer practical steps to reflect upon where your organization stands and where it might look to be in a referral model for community resources.

Starting point: Does your team have a useful resource library?

Useful is the key word here: we’re not talking about a static laundry list that simply names local community resources on a website or a print out. Useful resource libraries not only catalog existing community resources but also include pertinent details such as eligibility criteria. For example, at one organization we interviewed, health coaches use their electronic resource library to match the patient’s age, income, and residence profile with available community resources. To create the most useful resource library for your organization, we suggest querying your care team about what essential pieces of information would help them effectively and confidently refer patients to community resources.

Importantly, a resource library is only as useful as it is accurate and up-to-date. Organizations will need to identify who will monitor and update the resource library at regular intervals by visiting program websites, calling program contacts, or surveying providers about their experiences with listed community resources. For example, one organization we interviewed created a dedicated committee to appraise over 300 community resources that engage with their providers. Clearly, modifications to the resource library are to be expected, so electronic resource libraries (e.g. in a cloud-based platform or in the EHR) will be more dynamic than binders. Two organizations we interviewed are even using or contracting with companies that have created web-based resource libraries (e.g. Aunt Bertha, NowPow).

Next step: Who is responsible for referring patients?

Remember, the resource library is a tool not the solution. Organizations must lay out what roles will best enable referrals to community resources. Depending on your unique organization, referrals to community resources might be done through an entire team, an individual, or outsourced partners. For example, one larger organization we interviewed developed multidisciplinary teams of nurses and social workers, making specialized referrals and handoffs for particular social service domains (e.g. a housing team, transportation team, and nutrition team). In contrast, another organization used a single, centralized point person to make all referrals into the local community. Alternatively, two organizations we interviewed piloted with external partners (such as Health Leads) whose staff executes the referrals to specific community resources.

In addition to defined roles, organizations must not forget to develop associated workflows. What is the workflow to identify the patients with social service needs? What is the provider’s workflow to connect with whomever will make the community resource referrals? Are there workflows in place to follow-up regarding the referrals made to community resources? While developing these workflows, organizations need to consider what the preferred modes of communication are and which documentation platforms will facilitate the workflows. For example, one organization we interviewed built workflows into their EHR by tailoring the existing social service pathways of the Pathways Hub Model to fit the organization’s particular patient needs, staffing structure, and provider network. By strategically designing roles and workflows that support patient referrals to community resources, your organization shares responsibility for the success of the referral model.

Final move: Are you evaluating the impact?

Evaluating your referral model is crucial not only to intelligently decide what to keep, drop, or adapt but also to assess the impact of your work. All of the organizations we interviewed found it challenging to demonstrate that referrals to community resources directly influenced larger outcomes such as total costs of medical care. More immediately, data points that organizations may want to capture include the number of patients with different types of social service needs and the number of complete and incomplete referrals made to each community resource. For example, one organization we interviewed is tracking their rate of unsuccessful referrals to community resources in order to reveal where gaps in the community persist and subsequently inform advocacy efforts.

Furthermore, evaluating your referral model sets the foundation to build a business case for social service partnerships. A few organizations we interviewed were interested in entering financial arrangements with a curated network of community partners based on quality and other performance metrics, although these were generally still in the early stages of development. As organizations look to harmonize data collection and evaluation efforts, partners will need to agree upon the types of data, preferred reporting formats, and interval of reporting requests. In fact, based on interviews with community partners, we learned that many community partners are motivated to collect and exchange data on shared patients in order to improve their value proposition with grant funders and secure future funding.

Following the lead of innovative organizations, there are valuable opportunities for health care organizations to use a referral model with community resources. Health care organizations that leverage their local communities can more effectively match patients with comprehensive services critical to improving health status. Improving the referral model is a key step in connecting the dots between medical care and community resources, a small move toward systematically caring for the whole person rather than the discreet set of problems bringing a patient into a given provider’s office.

The authors are health services researchers at Dartmouth.

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  1. Any discussion of using a health plan resources for improving a community’s adversities that drive its Unstable HEALTH should begin with a broadly conceived, definition of the COMMON GOOD for a community. I offer the following:
    The COMMON GOOD may be defined as:
    …a community’s Clusters Of Benefits and Obligations —
    …..promoted by the community’s Social Capital asset,
    …..enhanced by the Family Traditions of its citizens and
    …..shared by the community among its citizens —
    …that are:
    …ENABLED by the moral obligation of its citizens to participate
    …in their community’s volunteerism with an intent to assure
    …that the community’s Benefits And Obligations for each citizen are
    …Equitably available, Ecologically accessible, Justly efficient and Reliably effective
    …for each citizen’s Personal Survival Plan;
    …INSTITUTED by the community to
    …”secure the Domestic tranquility” and “promote the general welfare”
    …for its citizens in accord with their Nation’s laws and regulations
    …currently applicable to the community’s governmental and
    …private institutions, at all levels;
    …OFFERED by the community to each of its citizens who may chose
    …from among their community’s unique Clusters of Benefits and Obligations
    …the specific Benefits and Obligations most suitable
    …for their own social and cultural environment within the community;
    …AUGMENTED by the periodic COLLECTIVE ACTION strategies
    …initiated from among the community’s citizens
    …to ameliorate a newly prioritized adversity
    …occurring for its citizens from a locally prominent discontinuity
    …among the community’s Clusters of Benefits and Obligations;
    …PROTECTED by the community’s annually revised Master Disaster Mitigation Strategy,
    …for anticipating and managing the community’s response
    …to the occurrence of certain disasters and their associated impairment
    …in the capability for a significant portion of the community’s citizens
    …to maintain their Personal Survival Plan; AND
    …SUPPORTED by the community’s
    …private and governmental institutions at all levels and
    …its Nation’s Autonomy within the marketplace arenas
    …of the world’s Resources, Knowledge and Human Dignity.
    As we know it, healthcare is a sub-set of a community’s Common Good. For a suspected new HEALTH Condition, the processes of ‘medical Triage’ govern a person’s entry into healthcare. Practically, most ‘medical TRIAGE’ occurs within the family, extended family or family/neighborhood/network. My bias is that most medical TRIAGE should increasingly be handled by a community’s Primary Healthcare and by their experienced RN level nurses who manage its phone triage during office hours. Other sources of medical Triage may be 911 for an emergent problems, social services triage managed by the local United Way, and 211 if there is 24 hour availability for managing homelessness. It gets really complicated by an order of magnitude after that. The most difficult is medical TRIAGE for mental health Emergencies. Many large communities are beginning to consolidate this at one location that has short stay capability divided separately into adults and adolescents/? other depended persons.
    All of this is very complicated for any hospital or health plan to implement any attempted improvement project. It is made worse by the absence of a nationally sanctioned process that is locally instituted and supported to function as a source for promoting Trust, Cooperation and Reciprocity among the relevant institutions. This would also be the means to assure that enhanced Primary Healthcare is equitably available to each citizen, coordinate collective thrust projects (especially early childhood development and adolescent health), and the annual review of the community’s Master Disaster Mitigation Plan. As a matter of perspective, an equally and newly considered definition of HEALTH is needed to a complete understanding of how a person’s HEALTH evolves during a life-time. Another time!