University of San Francisco California
Social care best practices: Learnings from a technology-enabled closed-loop referral network
Presentations from 2025 SIREN National Research Meeting: Advancing the Science of Social Care
Background: Closed-loop referral networks represent one emerging model to support cross-sector collaboration and deliver evidence-based non-medical interventions. These models establish efficient care pathways for individuals navigating community-based services like food, housing, and transportation. Yet, engaging communities around one system of record for care coordination is challenging work. We will discuss lessons learned from over a decade of supporting organizations’ adoption of closed-loop referral technology.
Objective: To (1) identify common barriers and facilitators to implementing and scaling tech-enabled care coordination platforms, and (2) measure the impact of care coordination platform adoption on administrative burden and feelings of burnout.
Methods: We conducted 103 semi-structured key informant interviews and 22 semi-structured focus groups with national Community-Based Organizations (CBOs), health systems, payors, and government agencies from October 2021 to December 2023. Common facilitators and barriers to implementing closed-loop referral technology were identified through iterative, thematic qualitative analysis using NVivo software. Two matched, pre-post end user surveys were administered to measure self-reported efficiency gains (n=101) and burnout (n=1,125) among software end users.
Results: The following themes emerged as “must-haves” when implementing and scaling tech-enabled care coordination: (1) Engaged Champions and Organizational Buy-in at all levels; (2) Embedding the “Why”; (3) Data-Informed Expectation Setting and Role Fit; (4) Consistent training and support; and (5) Network Adequacy (enough of the right partners engaged). When these are in place, compared to traditional care coordination methods, end users report a statistically significant efficiency gain of 13 minutes per referred case (p < 0.05) and statistically significant reductions in work-related burnout (p < 0.05).
Conclusion: As the regulatory and value-based care environment continues to shift toward incorporating social care coordination into the medical model, it is important to learn from those expected to do the work of implementing and scaling solutions to meet whole person needs.