17 July 2025

How Closed Loop Referrals and SDoH Screening Transform Emergency Department Overuse

Emergency departments (EDs) are designed to provide immediate care for life-threatening conditions; however, many hospitals and health systems across the United States face a growing problem: frequent and avoidable ED visits driven not by medical emergencies, but by unmet social needs. Factors like housing insecurity, lack of transportation, food insecurity, and inadequate access to primary care often push patients to seek help in EDs, even when their needs could be addressed more effectively through community-based services.

This pattern strains healthcare resources, increases costs, and leads to poorer health outcomes. As hospitals strive to reduce unnecessary ED utilization, two critical strategies have emerged: Social Determinants of Health (SDoH) screening and closed-loop referral systems. When combined, these approaches help identify underlying social needs and ensure that patients are connected to the appropriate community resources, thereby transforming care delivery and alleviating pressure on emergency services.

Understanding SDoH Screening

SDoH refers to non-medical factors that influence health outcomes, including economic stability, education, social and community context, health care access, and neighborhood environment. Research indicates that up to 80% of a person's health is influenced by these social factors, rather than clinical care alone.

Closed Loop Referrals and SDoH Screening Reduce Emergency Department Overuse

SDoH screening involves systematically assessing patients for these social determinants of health (SDoH) during clinical encounters. Screening tools, often integrated into electronic health records (EHRs), ask targeted questions to uncover challenges related to housing, food security, transportation, utility access, employment, and social support.

By identifying these needs proactively, healthcare providers can better understand the root causes behind frequent ED use and other high-cost care patterns. However, screening alone is not enough — there must be a reliable way to act on this information.

The Role of Closed-Loop Referrals

Traditional referral systems often rely on simply providing patients with information about community services or suggesting that they contact a resource independently. Unfortunately, these "open loop" referrals frequently fail, leaving patients without the support they need and driving them back to the ED.

Closed-loop referral systems address this issue by establishing a structured and trackable process for connecting patients to social services. In a closed-loop model, providers not only refer patients to external organizations but also monitor whether the referral was received, whether the patient engaged with the service, and the outcome of the service.

This loop of communication ensures accountability among healthcare providers and community-based organizations (CBOs), thereby providing patients with a sense of relief. By following through on each referral, healthcare teams can confirm that patients receive the necessary support to address social drivers of health, offering them reassurance and peace of mind.

Reducing ED Overuse: The Combined Impact

When SDoH screening and closed-loop referrals are integrated into ED workflows, the results can be transformational. By identifying social needs at the point of care and facilitating direct connections to community resources, hospitals can address the root causes that lead patients to seek emergency services inappropriately.

For example, a patient visiting the ED repeatedly for asthma exacerbations might be struggling with poor housing conditions, mold exposure, or lack of access to medications. Through SDoH screening, clinicians can identify these environmental and social factors. With a closed-loop referral system, they can then connect the patient to housing support programs, environmental remediation services, and financial assistance for medications, and track the outcomes.

Studies have shown that these combined strategies reduce repeat ED visits, improve patient satisfaction, and lower overall healthcare costs. Furthermore, they enhance equity by addressing the social inequities that disproportionately affect marginalized populations.

Real-World Success Stories

Several health systems have successfully implemented this model. For instance, some urban hospitals have partnered with local housing agencies, food banks, and social services to build robust closed-loop referral networks. By integrating screening questions directly into triage assessments, healthcare providers can quickly identify patients in need and refer them in real-time.

One health system in New York saw a significant reduction in non-emergency ED visits after implementing SDoH screening and closed-loop referrals, alongside targeted community partnerships. Patients reported higher trust in the healthcare system and felt better supported to manage their health outside the hospital setting. For instance, a patient who was repeatedly visiting the ED for asthma exacerbations due to poor housing conditions was connected to a housing support program, leading to a significant reduction in ED visits.

Another example comes from a Midwest health system that focused on food insecurity. Patients presenting at the ED with complications related to diabetes or malnutrition were screened for food access issues and connected to local food assistance programs. By closing the loop on referrals and confirming receipt of services, the system achieved measurable improvements in health outcomes and reduced reliance on emergency care.

Overcoming Challenges

Implementing these strategies presents challenges. It requires investment in technology that supports closed-loop referral tracking, training agents to conduct effective SDoH screenings, and building strong partnerships with community organizations.

Data sharing and privacy are also critical considerations. Health systems must ensure compliance with HIPAA regulations and maintain secure communication channels when sharing information with external partners to protect patient privacy.

Moreover, addressing social needs often requires coordinated funding and policy support. Policymakers play a crucial role in advocating for sustainable reimbursement models that cover social care interventions, which is essential to scale these approaches.

The Future of ED Care and Community Health

As the focus on value-based care grows, hospitals and health systems are increasingly incentivized to reduce unnecessary ED utilization and improve population health outcomes. SDoH screening and closed-loop referrals represent powerful tools to achieve these goals.

By shifting from reactive emergency care to proactive, community-integrated support, healthcare organizations can better serve patients, especially those most vulnerable to social inequities. Patients benefit from improved health, greater self-sufficiency, and enhanced trust in the healthcare system, gaining a sense of empowerment and confidence in their ability to manage their health.

Conclusion

Emergency departments should be a last resort for true medical emergencies, not a safety net for unmet social needs. By combining SDoH screening with closed-loop referral systems, hospitals can transform how they address the underlying drivers of health, reduce preventable ED visits, and strengthen community health overall./p>

As more hospitals adopt this approach, we move closer to a future where social care is seamlessly integrated with healthcare, ensuring every patient receives the proper support in the right place at the right time. This progress instills hope for a future where preventable ED visits are reduced and community health is strengthened.

GridSocial by SocialRoots.ai enables hospitals and community organizations to integrate SDoH screening and closed-loop referrals into their workflows seamlessly. With features like centralized intake, automated referral tracking, real-time reporting, and secure data sharing, GridSocial ensures that no patient falls through the cracks. By connecting individuals to vital social services and monitoring outcomes, you can reduce unnecessary ED visits, improve health equity, and enhance patient satisfaction. Ready to transform your approach to social care and community health? Choose GridSocial to build a stronger, more connected, and impact-driven referral and case management system. Learn more at SocialRoots.ai.

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