Closed-Loop Referrals Are Key to Social Care Success: Halima Ahmadi-Montecalvo, PhD, MPH

Social care programs that stop at the referral stage risk mistaking activity for impact, according to Halima Ahmadi-Montecalvo, PhD, MPH, adjunct professor of public health at the Milken Institute School of Public Health at George Washington University and vice president of research and evaluation at Unite Us.

"The referral that's just sent to the organization with no follow-through appears as a completed intervention in the data,” she said. “You see how that can create that false sense of success."

Referrals Without Follow-Through Mask True Outcomes

A closed-loop referral system does more than transmit a patient's information to a community-based organization, Ahmadi-Montecalvo explained in a recent article. It confirms the referral was received, tracks whether the service was delivered, and gives care teams visibility into the "care journey." Without that follow-through, critical variables, such as patient eligibility, organizational capacity, reachability, and service delivery, remain unknown.

That gap carries consequences for data integrity. A referral with no documented outcome can still register in a system as a completed intervention, creating what Ahmadi-Montecalvo described as a false sense of success. True value, she said, comes from knowing whether a patient actually received food support or whether transportation assistance improved appointment attendance and using that feedback to adjust care.

Fragile Workflows Signal Programs Built to Fail at Scale

Ahmadi-Montecalvo also pointed to warning signs that a social care program relies on unsustainable workarounds rather than durable infrastructure. Chief among them: dependence on a small number of highly committed staff manually tracking referrals through spreadsheets, emails, or phone calls, with key partner relationships tied to a single person's institutional knowledge. Programs limited to a narrow pilot population—one payer or a handful of community partners—may prove feasibility but not scalability across geographies and demand levels.

Built-for-scale infrastructure, she said, should standardize core workflows while allowing local flexibility and supporting shared accountability, real-time visibility, secure data exchange, and consistent measurement. Most critically, it must keep functioning through staff turnover, rising volume, and the end of grant funding.