Referrals

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Referral in Social Care

Referrals are critical in social care, acting as a bridge to connect individuals with specialized services, resources, or professionals to address complex needs that primary care or community caregivers cannot fully manage alone. In social care, referrals ensure that clients, such as older adults, people with disabilities, or those facing social determinants of health (SDOH) like housing or food insecurity, receive timely, coordinated, and holistic support. Below are key reasons why referrals are vital, with insights drawn from relevant sources:

• Access to Specialized Care and Resources: Referrals link clients to specialists (e.g., mental health professionals, housing coordinators) or community-based organizations (CBOs) that address specific needs, improving outcomes. For example, a caregiver using AbilityHub might refer a client to a food pantry to address food insecurity, preventing health deterioration.

• Improved Health and Social Outcomes: Timely referrals can prevent crises, such as hospital readmissions or worsening chronic conditions. Studies show that addressing SDOH through referrals (e.g., transportation or economic support) improves health outcomes and reduces care costs.

• Care Coordination and Continuity: Referrals foster collaboration among primary care providers, social workers, CBOs, and families, ensuring a seamless care continuum. In social care, where multiple stakeholders are involved, referrals prevent clients from “falling through the cracks.”

• Equity and Efficiency: Referrals align with health equity goals (e.g., CMS, Healthy People 2030) by connecting underserved populations to resources, reducing disparities. They also optimize resource use by directing clients to appropriate services, avoiding unnecessary duplication of efforts.

• Reduced Caregiver Burden: For social care organizations, referrals streamline workflows by delegating specialized tasks, reducing burnout. AbilityHub’s referral capabilities, for instance, could allow caregivers to focus on direct care while CBOs handle SDOH needs.

However, traditional referral processes often face challenges like manual data entry, communication gaps, and delays, which can lead to unfulfilled referrals (e.g., 46% of faxed referrals never result in appointments). This underscores the need for automated referral management systems in social care.

Automated Referral Management Functionality

An automated referral management system addresses inefficiencies in traditional referral processes, enhancing care delivery, operational efficiency, and client outcomes in social care. Below is a compelling case for developing such functionality, particularly for a platform like Fieldworker & AbilityHub:

1. Streamlined Processes and Reduced Errors:

   • Manual referrals, often reliant on faxes or paper forms, are prone to errors and delays. Automation digitizes the process, ensuring accurate data transfer and faster referrals. For example, Fieldworker could automate referrals to CBOs for housing support, reducing administrative burden.

   • Automation eliminates repetitive tasks (e.g., re-entering client data), allowing caregivers to focus on client care.

2. Improved Client Outcomes:

   • Automated systems ensure timely referrals, critical for addressing urgent needs like food insecurity or mental health crises. Studies show that prompt referrals improve recovery prospects and prevent complications.

   • Closed-loop referrals (tracking from initiation to completion) ensure clients connect with resources, increasing uptake rates (e.g., from 3% to 75% in some studies).

3. Enhanced Care Coordination:

   • Automation facilitates real-time communication among stakeholders (e.g., caregivers, CBOs, families) via integrated platforms. Fieldworker & AbilityHub could enable bidirectional referrals, where CBOs update caregivers on service delivery, improving trust and collaboration.

   • Interoperability with electronic health records (EHRs) or other systems ensures seamless data sharing, aligning with modern healthcare trends.

4. Cost Efficiency and Scalability:

   • Automated referrals reduce administrative costs by minimizing manual processes and unnecessary consultations.

   • Scalable systems can handle growing referral volumes, supporting social care organizations as partnerships with CBOs expand, as seen in the ACL Social Care Referrals Challenge.

5. Data-Driven Insights:

   • Automated systems track referral metrics (e.g., completion rates, wait times), enabling organizations to optimize workflows and demonstrate impact to funders or regulators.

   • The Fieldworker could use referral data to identify high-demand SDOH resources, informing community partnerships.

6. Patient and Caregiver Empowerment:

   • Automation improves client satisfaction by reducing wait times and providing transparency (e.g., referral status updates).

   • For caregivers, automated tools like those in Fieldworker reduce workload by staging referrals (e.g., pending, accepted), enhancing productivity.

7. Alignment with Policy and Technology Trends:

   • Policies like CMS’s push for SDOH integration and the rise of value-based care emphasize the importance of efficient referrals. Automated systems align with these goals by connecting health and social care.

Referrals in Fieldworker

The Ability Hub app supports the capture of SDOH data that can be used to identify referral needs. The Ability Hub portal keeps an up-to-date list of various community resources that can help refer patients/customers to the most appropriate provider.

Agencies on the Fieldworker platform can automatically create, accept, and efficiently manage referrals. The referrals can be sent and managed for

• a provider or community-based organization already using the Fieldworker platform (An agency currently using the Fieldworker app)

• a provider, or community-based organization, a part of the Fieldworker ecosystem (Part of the database of external service providers in the Fieldworker)

• any provider or community-based platform that is not yet part of the Fieldworker ecosystem

• Any individual, caregiver, or friend of a person requiring help

A referral generally has the following components

• A client, patient, or a prospect

• The agency initiating the referral (outbound referral)

• The agency receiving the referral (inbound referral)

• Information about the needs of the patient

• Information about the current state of the patient

While the bulk of the functionality in the Fieldworker platform is exclusively for its customers, the referral functionality is designed in a way to provide use cases for anyone and everyone, current fieldworker users, customers, external agencies, or any social care agencies.

Referral portal

The fieldworker platform has a dedicated portal for generating referrals that is available for everyone to use. The portal can be used to generate an inbound referral for any Fieldworker agencies. The portal can also be used to generate an outbound referral to any external companies. If the referred company is part of the Fieldworker ecosystem, the referral can be initiated and sent via electronic means. The same portal may also be used to generate a referral for any agency. Such referrals can be printed and then sent via traditional means.

Referral Settings

Any agency using the Fieldworker platform and subscribing to the referral functionality can define a unique string 'guid' that helps agencies to announce a dedicated link, which can be used by anyone to generate a referral to the agency. A company with guid 'abc' will have its dedicated link as https://referral.fieldworker.ai/abc. This link will display the inbound referral form set up by the agency.

An agency is expected to set up the following mandatory fields when using referrals in the Fieldworker.

• Unique guid that is used to generate a dedicated referral link

• Referral coordinator, an employee who receives all incoming referrals

• Incoming referral form (an agency can define its own custom inbound referral form, using Fieldworker smart forms)

• Outbound referral form (an agency can define its own custom outbound referral form, using Fieldworker Smart Forms)

• Incoming referral workflow, if the agency subscribes to the workflow automation and has automated the process using Fieldworker's Intelligent Workflows.

An agency using Fieldworker can publicly share its dedicated link for receiving incoming referrals. They can also generate a QR code, which can be shared to get easy referrals.

Incoming Referral

An incoming referral (usually generated via the dedicated link using the custom inbound referral form) received in the Fieldworker is handled as follows.

• An intake task is created and assigned to the referral coordinator

• An email notification is sent to the referral coordinator

• If the referral and/or intake process has been automated using the Intelligent Workflows in the Fieldworker, an instance of this workflow is also created.

Outgoing Referral

An outgoing referral can be generated by a Fieldworker user company either from a customer page or from the Referral dashboard. An outgoing referral for another Fieldworker agency will be handled as an incoming referral, as explained above. An outbound referral for an external company with which the Fieldworker platform has interoperability will be sent automatically using electronic means.

All outgoing referrals will be recorded in a referral table, along with their current status. All referrals, both incoming and outgoing, will be accessible from the Referral dashboard.

Referral Dashboard

The Referral dashboard is the primary interface to manage all referrals in the Fieldworker. The Dashboard lists all referrals and lets a user check status, take actions, and make interventions, where needed.