Tackling social determinants of health (SDoH) demands going a step ahead of “closed-loop referral”. Community and health partners must continuously collaborate to solve the challenges of vulnerable people.

Let us suppose Ann is a pregnant mother on Medicaid. She lacks reliable transportation thus, causing her to miss prenatal visits. Conventional wisdom would believe that sending her a referral for ride-sharing service would solve her social needs. But, this wouldn’t solve the issue.

In reality vulnerable people and their families don’t experience SDoH one at a time. They experience complicated and interrelated issues. So, providing a “closed-loop referral” doesn’t reveal who Ann was prior to the appointment, what transpired during the appointment and when she went home nor about her social factors influencing her maternal health outcomes.

Organizations require visibility into the full timeline of life challenges faced by Ann. Does she need financial assistance for prescriptions? Is she without healthy food, which raises risk for gestational diabetes?

What is required is true collaboration between a thriving network of community and health partners. Thus, bringing together payers, providers, agencies and community organizations on one shared network allows these virtual teams to collaboratively solve Ann’s complex social needs.