Session 3: Identifying Community Resources, Making Referrals to Community Based Organizations, and Evaluating Closed Loop Referral Platforms

Once your organization has compiled information about your patient’s social risk factors the next step is to identify the needs your organization wants to address and to identify community-based organizations (CBOs) that can provide the necessary services. Organizations need to develop or obtain a comprehensive list of available community-based organizations and services; establish a process for making referrals; and developing an approach for tracking the status and outcomes of those referrals. They also need to identify a network of reliable high-quality CBOs to work with. Many health systems have begun purchasing closed loop referral systems – information networks that help patients and providers identify community resources, make electronic referrals and track outcomes. Companies offering closed-loop platforms include findhelp (formerly Aunt Bertha) and UniteUS. However, closed-loop platforms are not for everyone. They are expensive and customers may need to expend significant resources on staff training an data integration.. This session discusses the features available on closed-loop referral platforms and considerations in the decision to use a platform including staff training, primary care workflow, and electronic medical record integration. It also discussed different approaches to selecting CBO partners, establishing contracts, onboarding CBOs into a network and monitoring performance.

SDoH Community Resource Guides Referral Tracking & CBO Networks
Presenter: Ashley Fitch, Director, Community Health Innovations & Partnerships
Mount Sinai Health System
Date: December 2, 2021
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Issue Brief: Building Community-Based Organization Networks to Assist Patients with Social Needs