Closed Loop Referrals: Can They Improve Behavioral Health Outcomes?

Individuals with behavioral health conditions have significantly higher rates of hospital readmissions. In too many cases, the underlying reasons for these readmissions go way beyond the healthcare system and are inextricably linked to the many social determinants of health (SDoH) factors. In order to impact these factors, all too often significant responsibility is placed on patients to navigate a maze of referrals, in a complex healthcare ecosystem. It’s no wonder that referrals and follow-up care often aren’t kept.

But the negative impacts, on both patients and the healthcare system, drives a need to reduce the high rates of hospital readmissions:

• Worsening physical and mental health outcomes

• Higher medical costs and avoidable emergency department utilization

• Interruption of community integration and stability

• Provider burnout

Take this representative clinical example:

Maria, a 32-year-old woman has been diagnosed with Bipolar I Disorder. She has a history of frequent hospital readmissions due to severe manic and depressive episodes. Her condition has been complicated by non-adherence with medication, lack of a robust support system, and inadequate follow-up care. Since her diagnosis, she has been admitted to the hospital six times over the past seven years, with an average of two readmissions per year. Her hospital stays are typically precipitated by a combination of medication non-adherence, substance use, and high-stress life events. With minimal family support and few friends, she is often isolated and has inconsistent employment history, exacerbating financial stress and access to care. With only public transportation as an option, its unreliability impacts her ability to attend follow-up appointments consistently.

This underscores the need for targeted interventions and enhanced care coordination between levels of care and providers in order to address the high readmission among individuals with behavioral health conditions. Efforts to reduce these rates must improve post-discharge support, ensure community-based care connections, and address the specific needs of this vulnerable population. One way to ensure a “stickier” connection between levels of care and providers are Closed Loop Referrals (CLRs).

The key elements of CLRs include:

Identification: Provider identifies the need for additional services (e.g., psychiatric consultation, substance use treatment, food pantry, entitlements, etc.) and initiates a referral.

Tracking: The referral is tracked through an electronic health record (EHR) or specialized referral management system to monitor if the patient receives the recommended service.

Feedback: The specialist or referred service provider reports back to the referring provider with the outcomes or next steps, thus closing the loop and in the process establishing a connection between disparate elements of the larger community network.

Follow-up: The referring provider engages with the patient in order to ensure adherence to recommended treatment or services, addressing any barriers to follow-up care with consequently improved outcomes.

This coordinated approach promotes completion of referrals. It contrasts with prevalent open loop referrals, where the referring provider might never know if the patient followed through with the referral.

During her hospital stay, Maria is once more stabilized on her medication regimen. Recognizing the impact of the many SDoH factors that contribute to her overall wellbeing and community stability, the hospital team employs their CLR system to ensure her medical, psychiatric and social needs are addressed.

Recent policy changes, especially for Medicaid, have heightened the importance of CLRs. Medicaid's new mandates emphasize whole-person care, integrating behavioral health with physical health services. Additionally, there is a growing appreciation for SDoH, such as housing stability, transportation, education, and access to nutritious food, which significantly impact health outcomes. CLRs have the potential to ensure that these diverse needs are met by more effective tracking of patient referrals and follow-ups, thus facilitating comprehensive care.

Several states recognize the importance of CLRs, including North Carolina, Colorado, California, and New York, that have started implementation. Integrating CLR within the health care systems, especially under the new New York State (NYS) 1115 waiver provisions, is a transformative approach to addressing the multifaceted needs of individuals with behavioral health conditions. The waiver provisions emphasize strengthening System of Care Networks (SCN) and IT infrastructure, which are crucial for effective CLR implementation. By leveraging advanced IT infrastructure, providers can systematically identify and address health-related social needs (HRSN), ensuring that patients receive comprehensive, coordinated care.

With a CLR system in place, Maria’s overall stability improves significantly. She successfully connects to her follow-up clinic, which helps her secure stable housing, receive regular meals, and find part-time employment through the job placement program. Her adherence to medication and follow-up appointments improves, leading to a significant reduction in hospital readmissions. Over the next six months, Maria does not require hospitalizations, marking a significant improvement in managing her Bipolar Disorder.

Making Closed Loop Referrals More Successful

Despite efforts, CLRs currently work sub-optimally. Low usage rates of referral technology platforms indicate that many providers lack training and awareness about CLRs or find these systems time-consuming. Missing integration with EHRs are costly, not a top priority for healthcare organizations. But workarounds create gaps in compliance with data privacy regulation, risking patient trust.

To make CLRs work better, we need a multifaceted approach:

1. Enhanced Training and Education: Healthcare providers must understand the value of CLRs and receive training on how to use the technology effectively.

2. Streamlined Processes: Simplifying the referral process with robust integration to EHRs can reduce the burden on providers, making it easier to integrate into their workflow.

3. Incentivizing Usage: Providing incentives for healthcare providers to use CLR systems can increase adoption rates.

Technology plays a critical role in the success of CLRs. Advanced platforms can facilitate seamless communication between providers, track patient progress, and provide real-time updates. AI and machine learning can predict which patients are most likely to benefit from follow-ups, enabling targeted interventions. Moreover, integrating these platforms with EHRs can streamline the process, making providers more likely to adopt them.

While technology is essential, it is not a panacea. There are limitations to consider, such as data privacy concerns, the need for robust cybersecurity measures, and the potential for technology to become outdated quickly. Moreover, technology alone cannot address the human element of healthcare—empathy, understanding, and personal connection are vital components that technology cannot replicate.

Call to Action: Transforming Behavioral Health Through Closed Loop Referrals

As we continue to witness the profound impact of SDoH on individuals with SMIs, it becomes imperative to adopt innovative approaches that ensure comprehensive and continuous care. Now is the time for healthcare providers, policymakers, and community organizations to act. By implementing CLR systems, supported by advanced IT infrastructure and a focus on SDoH, we can reduce hospital readmissions, improve patient outcomes, and create a more resilient healthcare system.

By prioritizing training, streamlining processes, and leveraging technology, we can ensure that patients like Maria do not fall through the cracks. It’s time to take action, not only to comply with policy changes but to genuinely improve patient outcomes and enhance the efficiency of our healthcare system. Together, we can create a healthcare environment where no patient is left behind.