Closing the Loop: How Referral Systems Are Transforming Health Care
Published Oct 22, 2025
In today’s health care landscape, addressing a patient’s medical needs is only part of the equation. Nonclinical factors — like housing, food access, transportation and safety — play a critical role in an individual’s overall well-being. That’s where closed-loop referral systems come in.
What Is a Closed-Loop Referral System?
A closed-loop referral system is a two-way communication process between health care providers and third-party organizations. When a provider identifies a patient need — clinical or nonclinical — they refer the patient to another provider or community-based organization. The loop is “closed” when the provider confirms that the patient has received the recommended support.
This system is especially valuable for patients facing challenges beyond the exam room, such as housing insecurity, food shortages or exposure to violence. By ensuring follow-through, closed-loop referrals help bridge the gap between health care and social care.
Collaboration Between Health Care and Community Organizations
Health care organizations often partner with CBOs to meet patients’ nonclinical needs. These partnerships can be direct or facilitated through social care technology platforms like Unite Us or Findhelp. These platforms streamline the referral process by:
- integrating social needs screening into electronic health records
- sending referrals to appropriate services
- tracking outcomes to ensure patients receive support
This collaboration creates a more accountable and efficient care ecosystem, reducing service gaps and improving patient outcomes.
A Real-Life Example: Supporting a Pregnant Patient
Consider Claire, a pregnant woman who visits the ER for an unrelated infection. During her visit, a nurse screens her for nonclinical factors that can impact her health and discovers she lacks prenatal care and stable housing. This information is uploaded to her EHR and flagged by the hospital’s closed-loop referral platform.
A care coordinator steps in, helping Claire schedule an appointment with an obstetrician and connecting her with a local housing support organization. The coordinator then follows up to confirm Claire received both services. This proactive approach ensures Claire’s health — and her baby’s — is supported holistically.
Addressing Concerns About Cost and Complexity
Some organizations may hesitate to adopt closed-loop referral systems due to perceived costs or complexity. However, the long-term benefits often outweigh the initial investment. Key considerations include:
- securing leadership buy-in from both health care and CBO partners
- involving patients in system design to ensure their needs are met
- choosing platforms that integrate with existing EHRs
- acquiring funding to fairly compensate CBOs
When implemented thoughtfully, these systems can reduce avoidable health care use and generate significant cost savings.
Promising Outcomes From the Field
Data from Missouri offer compelling evidence of the impact of closed-loop referral systems. For example, Children’s Mercy Kansas City partnered with Innovaccer and Findhelp to launch a screening and referral process across 36 clinics. Between 2020 and 2023, their screening rate rose to 79%, with nearly 198,000 screenings conducted. More than 16,000 patients had social needs identified and coded using ICD-10 Z codes.
Monthly closed-loop referrals jumped from zero in early 2021 to more than 300 by early 2024. Families received help with job interviews, food access, bill payments and clothing — leading to better health outcomes for children.
Closing the Loop for Better Health
Closed-loop referral systems represent a shift toward holistic, patient-centered care. By ensuring that referrals are tracked and completed, health care providers can address the full spectrum of patient needs, from clinical treatment to social support.
As more organizations embrace these systems, we’re seeing real-world improvements in health outcomes, patient satisfaction and operational efficiency. The investment may require thoughtful planning and collaboration, but the payoff is clear: healthier communities, empowered patients and a more connected health care ecosystem.
The MO PQC, in collaboration with the Missouri Hospital Association, released a publication on the importance of screening for nonclinical needs and how hospitals and providers can meet these needs by using closed-loop referral platforms and processes.