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

After you have compiled information about your patient’s social risk factors the next step is to establish priorities for the needs your organization wants to address and identify reliable, high-quality community-based organizations (CBOs) that can provide the necessary services. To do this organizations need a comprehensive list of available community-based services, a system to make referrals and receive timely information about the status and outcomes of those referrals and a network of reliable high-quality CBOs it will work with. Organizations are increasingly purchasing closed loop referral systems – are information networks that help patients and provider groups identify community resources and track the outcomes of community service referrals. Many contract with companies like findhelp (formerly Aunt Bertha) and UniteUS for these services. This session discussed the features available on closed-loop referral platforms and discuss key considerations using the platforms including staff training, incorporating these tools into primary care workflow and integration with electronic medical records. It also provided guidance on selecting CBO partners, establishing contracts, onboarding 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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Brief: Building Community-Based Provider Networks to Assist Patients with Social Needs: Key Issues for ACOs