Lessons Learned: Real-World Recommendations for Building a Community Resource Referral Platform

This post is a direct result of NCQA’s promise to research and recommend resolutions for addressing inequity and the social determinants of health (SDOH). We’re going to want you to match our work here with some suggestions of your own.  More on that later.

Delivering high-quality care requires collaboration across the health care and social service sectors. We recognize the importance of addressing SDOH as part of improving care delivery, health outcomes and health equity. Many organizations are considering technology to connect health systems, medical homes and community-based organizations (CBOs) for purposes of care coordination, joint care management and closing the referral loop by letting medical homes know the outcome of patient referrals to CBOs. Many are considering community resource referral platforms to make the connection.

Community Resource Platforms

Community resource referral platforms have two key functions – they provide an up-to-date resource directory and facilitate tracking of referrals. These platforms are still new to the healthcare landscape, and early adopters are beginning to share lessons learned.

So, NCQA collected lessons learned and recommendations from one specific technology implementation that connects medical homes with CBOs.  Medical Home Network’s platform is used for Medicaid managed care beneficiaries in Cook County, IL, and is designed to facilitate collaborative care coordination and information sharing. A resource directory and referral tracking will be integrated into the overall platform as part of the implementation.

Platform Implementation: Our Review

During our review, we identified 17 lessons learned and 44 associated recommendations that will be useful for other implementors, health systems, and CBOs embarking on this journey.

nurse computer platform

At first review the number of challenges that can arise can seem daunting – it truly does show how many things need to go right, and how many people and organizations need to be aligned and involved to make transformation projects successful. As such, we targeted each lesson and recommendation to the specific people and organizations who can take action.

We believe these specifically detailed lessons and recommendations will be helpful for certain stakeholders at different stages of the implementation. We have provided a brief overview table of our recommendations, as well as a more comprehensive document describing them and filterable excel tables so you can easily access information with the level of detail that best meets your needs. We created this tool to help organizations implementing referral platforms create a project work plan that will help them avoid or mitigate common challenges.

Platform Implementation: Tools and Discussion for Success 

To see the details and contribute to the discussion, join us in the Digital Measurement Community where we’re hosting an online discussion—one where you may share your own thoughts and recommendations for building a platform similar to the one Medical Home Network now uses.

We know this work only improves when you have an opportunity to weigh in. We hope you will.

We also hope you’ll download and check out the resources below. We’ve put them together to help with your work and to prompt your participation in our discussion.

They include:

Implementing a Community Resource Platform: Executive Summary

Implementing a Community Referral Platform – Lessons

Lessons Learned and Recommendations Tables

Here are instructions for new users on how to register for the DMC:

Share your experience and join the conversation at our Digital Measurement Community discussion.

  1. Go to: https://www.ncqa.org/digital-measures/.
  2. Click the blue “Get Access” button on the top right.
  3. Click “Create Account” on the bottom right, enter information, and click the “Submit” button.
  4. Scroll down to mid-page and click on “View Community Forum”.
  5. Click on “Latest” to find the “Implementing a Community Referral Platform” post or Click on “Digital Innovation” underneath the category on the left to locate “Implementing a Community Referral Platform” or search “Implementing a Community Referral Platform” in the search bar on the right-hand side of the banner.
  6. Once the post is located, comment by clicking “Reply” on the bottom right of the post.