Design and Framework of a Technology-Based Closed-Loop Referral Project for Care Coordination of Social Determinants...

Screening for social determinants of health (SDOH) has been mandated by health systems nationwide. However, a gap exists in closed-loop referral for care coordination between health care and social services. This article presents the framework of a technology-based project to facilitate closed-loop referral between health care and social service agencies in Greater Houston by leveraging and connecting the existing care coordination technology infrastructure. Ten health care and social service organizations in Greater Houston participated in the demonstration project initiated in January 2023. The authors leveraged and linked regional health information exchange (HIE) technology with a master patient index of >18 million, and sector-specific care coordination platforms to build closed-loop referral capacity between HIE-participating health care organizations and social service organizations to meet patient SDOH needs. Evaluation efforts will assess the reach, adoption, implementation, and the effectiveness of the closed-loop framework in improving social and health outcomes. The framework comprised the following 4 components: (1) establishment of collaborative governance for shared decision-making processes, fostering trust, alignment, and transparency among organizations; (2) development of technology linkages between existing platforms to facilitate seamless referrals between organizations and ensure visibility of referral outcomes; (3) integration of regional resource directories into technology infrastructure to ensure resource accessibility/quality; and (4) evaluation of the system's impact on health equity, efficiency, and cost reduction. This project aimed to close the loop for care coordination between health care and social service agencies, enable data evaluation to determine care coordination effectiveness, and lay the foundation for SDOH-related research/practice equitably.