Table 3.

Implementing Social Needs Referral Platforms Was More Challenging than Expected

Expectation	Reality	Challenges
Platform will be used by all clinical staff.	Only staff providing referrals use the platform.	• Staff are unaware of or uncomfortable using platform. • Referrals are often seen as the work of care management. • Staff may not have time during a clinical visit to use the platform.
“I suspect what will happen is that [referral platform] will be used by the front desk and the MA in the practice, and so by siphoning off those maybe lower risk patients who you can just use Aunt Bertha to get them to the right resource, that will not clog up the care manager workload.” – Health system	“Our original idea was to allow the data system to generate a tailored community referral summary by having the clinician, or the medical assistant check off the individual resources that they wanted to refer a patient to. But that very quickly became a very tedious task that was too much to ask of the clinics.” – AHC
Integrate platform into existing technology.	Platforms and EHRs may not integrate easily.	• Staff have limited capacity to assume new responsibilities. • Referral platforms do not easily integrate into EHRs, requiring staff to toggle between programs.
“So, that is sort of a future functionality that we’re talking to [referral platform] about, is how do we take the information we collect from the screening tool and match it to the eligibility criteria that’s listed in the resources to create an even more refined list.” – AHC	“We have this integration whereby the screening results are sent in real time and the patient’s demographic information to [platform]. The clinical assistant does need to click into [platform]. It’s a same sign-on, not single sign-on.” – AHC
Resource list will be managed by the vendor.	Platforms still require time to set-up and update.	• Informal CBOs may not be included in platforms (e.g., churches). • Updates in the referral platform may be cumbersome.
“A challenge across keeping some sort of a community-based resource list is upkeep of it and who owns it, so this, we know will be something that’s kept updated by [referral platform]” – Health system	“They’re constantly changing and so you need to have the ability to make sure that if you have a database of resources like that, that it’s kept up to date. I don’t think there’s a great system for that yet.” - Health system
CBOs will use platforms for closed loop referrals.	Closed loop referrals require workflow changes.	• CBOs have existing systems for managing patients • CBOS may not want to adopt the referral platform. • Health care organizations and CBOs may not have the staffing capacity.
“Once [referral platform] is up, we will have far more capability of not just sending a referral but tracking the referral. Because as you know, right now for most of us in the world, when we give people information or even if we set up a referral, we don’t know what happens.” – Health system	“We tried to push the closing the loop piece right away, and what we learned is that we really need to get people in the system, used to it, navigating it, make sure people feel comfortable that everything’s accurate in the system. And then we can start really partnering with some of our key [CBOs], to start pilot testing...” - Health system
Platform will serve as a community resource.	Multiple organizations may launch a platform.	• Challenging for health care organizations to share a platform across a market • CBOs may not be able to effectively partner with multiple platforms and health care organizations.
“The way the interface is being developed, the patients themselves will also be able to interact with it.” – Health system	“And so the risk with a potential separate system was that we would end up without a community centered solution, but disparate systems, which would create more chaos in the community organizations” - Health system

Notes: CBOs community-based organizations, AHC accountable health communities, EHR electronic health record