How Community Resource Referral Platforms Improve Health Equity

Sarah Carroll, Director, Center for Care Transformation, and Sasha Cukier, Senior Analyst, Digital Impact Hub, AVIA


For a state known for being “Minnesota Nice,” my neighbors and I experienced a reckoning in 2020. George Floyd, a 46-year-old Black man, was killed just three miles from my Minneapolis home, in a neighborhood where the life expectancy is 10 years shorter than the rate in the suburbs to the west. With COVID-19 raging through my community, hitting my neighbors of color especially hard, Mr. Floyd’s death was a painful reminder of the facade that is “Minnesota Nice” and the work we have to do to address racism and health-related racial disparities. – Sarah Carroll

Across the country, COVID-19 exposed inequity in access and outcomes. Some of the starkest reports showed that low-income and communities of color had fewer accessible testing sites and Black and Hispanic patients died from the virus at over twice the rate of white patients. 

While the pandemic exposed severe disparities in health care, health inequities existed long before COVID-19 arrived, as the following statistics demonstrate:

Health equity means increasing opportunities for everyone to live the healthiest life possible, no matter who they are, where they live, or how much money they make. Health systems work to deliver more equitable care, with diversity initiatives, community health workers, and targeted social determinants interventions. Are these steps enough to affect change? How do they fit into other community-wide initiatives? Health systems must leverage digital to accelerate their reputation as a community asset, address growing social and behavioral health needs, and protect their margins. 

Digital solutions, implemented in collaboration with community-based organizations, are powerful tools to help address health inequity. AVIA identified 11 essential digital solutions to advance health equity. One solution, community resource referral platforms, should be a priority for health systems looking to improve access to care, care quality, and patient satisfaction, while reducing disparities.

How community resource referral platforms help combat health inequity 

85% of physicians say unmet social needs directly lead to worsened outcomes – for example, 51% of people with two or more ED visits report food insecurity. Underserved communities have greater social and behavioral health needs and lower access to whole-person care. Community resource referral platforms help increase opportunities for patients to live their healthiest lives. They can reduce avoidable ED visits and save over $1,500 per patient per one social need met.  

While providers frequently initiate action to factor social needs into care, those efforts often fail because patient conditions weren’t considered. In a Boston University study, 70% of patients were screened for social needs and 82% were referred to community resources upon visits. However, only 19% of patients followed through with the referral, due to transportation challenges or eligibility requirements. Community resource referral platforms improve follow-through by helping providers offer customized referrals based on location, language, eligibility, and transportation opportunities. 

Additionally, advanced community resource referral platforms improve patient engagement by accounting for communication modality preferences. Historically, many providers have relied on the spoken word, paper or email to send referrals. Instead, top-tier platforms use text messages to communicate with patients, as SMS texts are one of the best ways to reach low-income individuals. 92% of adults earning less than $30,000 have a mobile phone and 68% have a smartphone. 

“What good looks like” for community resource referral platforms

AVIA estimates that deploying a community resource referral platform can lead to $3.5 million in savings for a health system serving 100,000 Medicaid patients. In one study, patients who had their social needs met with the help of community referrals saved $2,443 in additional healthcare expenditure per patient over two years.  

A strong community resource referral strategy involves digital social needs assessments implemented across the whole system, offering providers the screening data they need to adequately and accurately understand patients’ social needs. Based on assessment findings, the platform identifies a current list of community-based organizations to meet patient needs and recommends priority resources based on eligibility, availability, and proximity. For example, if a provider learns that a patient is food insecure, they can quickly refer the patient to a nearby food pantry, taking into account the patient’s transportation and schedule limitations. 

Advanced platforms also collect data on patient use of referrals and aggregate data to evaluate patient engagement, outcomes, and gaps in community resources. This information can be invaluable to health systems looking to make a business case for digital action and improve future patient care. 

Using digital community resource referral platforms, health systems can streamline referrals to essential resources, improve access to care for underserved patients, and create additional operational value and efficiency. 

Overcoming barriers to adopting community resource referral platforms

There are barriers to effectively rolling out a referral platform. Working with stakeholders to overcome these barriers is essential for a successful adoption of the platform.  

Alignment: A community’s health systems, payers, and community-based organizations must collaborate on the same digital solution. In the absence of a common solution, communication, coordination, and referral management will be more difficult and less efficient.  

Care team communication: Community health workers are well-equipped to screen for social needs and support patients through their referral journey. Providers and other front line staff can learn from community health workers and familiarize themselves with approaches such as empathetic inquiry, active listening, and cultural competency, and prioritize social screening and referrals to improve patient interactions and outcomes. Speaking to patients about personal matters may be challenging at first, but failing to do so leads to overutilization of emergency care and worse outcomes. 

Build or buy: Health systems may try to build capabilities into their existing electronic health records (EHRs) to avoid making another digital investment, but EHR capabilities only go so far. Often, the manual maintenance of community resource directories prohibits achieving maturity in community resource referrals.  EHRs are a vital piece of the ecosystem, but not the only piece.

What the future of community resource referral platforms looks like

As organizations recognize how community resource referral platforms improve health equity, we will see a shift toward more robust, comprehensive uses of the platform: 

  • Identifying high-risk patients: Referral platforms will prompt providers when a patient is likely to be at risk for a social need to address during routine visits. The platform will also aggregate a list of patients likely to be at high-risk for an avoidable ED visit and readmission so care teams can proactively reach out with referrals and direct services. 
  • Customized communications: Patients will receive a message in their preferred modality, whether that’s text, email, or a phone call in their chosen language. The referral message will include the community organization that can best meet their needs. This communication will make follow-through on the referral easier for the patient, and the platform will proactively reach out to the patient to ensure they visited the referred organization.
  • Care insights: The digital platform will generate insights on patient outcome changes, such as food security status or ED utilization, and produce monetized savings data to the health system or payer. Interoperability between platforms will facilitate data sharing across healthcare organizations and community organizations. 

Advance health equity with AVIA

Community resource referral platforms are an important component in providing equitable care to your patients. If your organization is ready to make the shift toward digital community referrals, the experts at AVIA’s Center for Care Transformation are here to help. Contact us today to learn more about how digital can transform your referral program.