Screening Many, Helping Few: Community resource referral platforms struggle to reduce barriers to care

There is a robust and growing market for technology-based platforms that enable linkages between healthcare providers and local ecosystems of community-based or social service organizations. But how well do these platforms address social needs for the average patient or client? The data doesn't tell a good story.

The baseline against which to compare the performance of these platforms is the 211 helpline system, which connects economically vulnerable Americans with needed health and social services (like food banks or pantries) in their communities. These free information and referral services help people access services through more than 200 call centers covering all fifty states. Nationally, the helplines made over 12.8 million referrals in 2018.

In 2016, researchers at Washington University in St. Louis published the first analysis of how 211 services help callers resolve their problems:

• In a study of 1,176 callers, they found that problem resolution rates for all callers ranged from 25% for employment to 64% for food assistance. 
• Overall, only half of all 211 callers reported at a 1-month follow-up that their problem had been resolved.
• Only 36% of callers who contacted social services from a 211 referral indicated that they received assistance. The most common reasons for not receiving assistance were the referral agency not having funds (34%) and the caller not qualifying for services (25%).

The nation's 211 helplines do an amazing job of helping Americans navigate their local resources. But for many reasons, only half of the callers actually get their needs met. Do electronic referral platforms do the job in a better way?

How do new electronic social referral platforms compare to 211? 

Electronic referral management platforms promise that they could potentially make linkages to social services more efficient and effective by providing electronic community resource directories and facilitating referrals to social service agencies. Only one study has been published, which reports the rate of community resource use resulting from an automated intervention delivered under real-world conditions.

This study, CommunityRx: A Real-World Controlled Clinical Trial of a Scalable, Low-Intensity Community Resource Referral Intervention published in the American Journal of Public Health, tracked the outcomes from more than 113,000 outpatients who received a referral to a community resource. Among this population:

• Only 14% of patients reported using a community resource based on this electronic referral.
• Further, the new intervention did not demonstrate any significant effect on mental or physical health-related quality of life.
• Electronic referral platforms do not improve outcomes over the standard of care provided by 211.

Why do community resource and referral platforms struggle to help?

The goal of closed-loop referral tracking is for the referral sending organization to find out what happened after a referral is made. Even with an electronic referral management platform, closed-loop referral tracking is the most challenging part of the implementation of a new integrated model of care because it requires information from either the social services organization or the patient. Researchers at SIREN at UCSF say the most common challenge in this effort is recruiting community-based social services organizations to use the platforms, which was necessary for health care organizations to be notified of referral outcomes. 

Community partners do not usually have clear incentives for using a new electronic platform, and the resources required for implementation prevents many organizations, especially very small ones, from adopting a platform. As a result, many referral platform customers are not able to track referral outcomes, despite the fact that this was one of the primary reasons why they had initiated platform adoption. The SIREN team also explicitly advises communities not to assume that patients are using electronic referrals. This is consistent with the CommunityRx study data presented above.

Why don't electronic referrals work?

Social needs are intersectional, dynamic, and difficult to address. An electronic referral to one service for one need is generally not sufficient to meet the multiple and complex issues affecting people with complex health and social needs.

Research has consistently indicated that despite acute needs, people experiencing social needs can be reluctant to engage with helping services. Barriers to service engagement include a lack of awareness about services, which electronic referral platforms help to alleviate. But other, more pressing barriers include service inaccessibility such as waiting lists and service location, concerns about confidentiality, not wanting to engage with strangers or tell one’s story repeatedly, mistrust of service providers, feeling judged or that staff have ‘agendas’, lack of perceived need for mental health services, a belief that services are not helpful, or disliking needing help.

As a strategy for improving outcomes, care coordination involves deliberately organizing  care and services and sharing information among all of the members of a care team. An electronic referral intervention without a care coordination strategy is not actually designed to address social needs. The role of a care coordinator, community health worker, or social worker is critical to help individuals access the services they need.

What steps can communities take to avoid electronic referral failure?

• Before you start, make sure all organizations in the referral network are willing to actually be a recipient of a referral. If all partners are invited to the table early on, it helps them to understand really what's being asked of them. Referral network leaders should engage their partners early on and ask them what their concerns are.
• Invest time upfront assessing options and priorities for the referral network’s care model, and which professionals in the community will be helpful in addressing social and economic factors. It is important to think through these larger system and workforce issues.
• Activate Care offers substantial functionality for social service organizations as a way to increase the use of the platform by these organizations. With care coordination and case management tools, social services organizations more efficiently make and manage referrals to other social service agencies, track outcomes, document the organization’s value to health care organizations and other stakeholders, and track clients electronically. 

The common thread that runs through everything in a successful social needs intervention is the importance of centering the network connections around authentic healing relationships. The data is clear - a referral network without a care coordination strategy simply does not meet social needs.