Community Resource Linkage

A curated, searchable database of community-based organizations (CBOs) mapped to standardized social need categories. Each resource entry includes:

• Service type (food pantry, rental assistance, transportation)
• Eligibility criteria (income thresholds, geographic boundaries, age restrictions)
• Capacity status (accepting referrals, waitlist only, temporarily closed)
• Contact details and hours of operation

Alignment with the Gravity Project terminology ensures resources are categorized using consensus-driven value sets compatible with FHIR SDOH observations.

An automated rules engine that compares a patient's extracted SDOH profile against resource eligibility criteria to generate appropriate referrals. The engine evaluates:

• Geographic proximity using geocoded patient addresses and service area boundaries
• Demographic fit including age, family composition, and veteran status
• Insurance and income requirements against program thresholds
• Service availability in real time to avoid dead-end referrals

This eliminates manual matching by care coordinators and reduces referral rejection rates.

A bidirectional communication channel that tracks the entire referral lifecycle from initiation to outcome. The workflow includes:

• Electronic referral submission via secure API or direct platform integration
• Acknowledgement tracking confirming the CBO received the referral
• Status updates as the patient progresses through intake, service delivery, and completion
• Outcome reporting capturing whether the social need was resolved, partially met, or unmet

This closed-loop architecture provides population health analytics on referral effectiveness and identifies gaps in community resource capacity.

A standards-based interoperability layer that exchanges social risk data between the linkage platform and electronic health records using the HL7 FHIR SDOH Clinical Care Implementation Guide. Key capabilities:

• FHIR SDOHCC Observation resources for screened social risk findings
• FHIR ServiceRequest for formal referral orders to community organizations
• FHIR Task resources to track referral fulfillment steps
• FHIR Procedure to document completed services

This ensures social care data flows seamlessly into the patient's longitudinal record, supporting USCDI SDOH data element compliance for certified health IT systems.

A unified interface for care coordinators, social workers, and community health workers to manage patient referrals at scale. Features include:

• Real-time referral queues prioritized by urgency and SDOH risk stratification
• Patient-level referral history showing all active and historical linkages
• Bulk referral capabilities for population-level interventions
• Analytics views tracking referral acceptance rates, time-to-service, and outcome distributions

The dashboard surfaces model confidence scores from the SDOH extraction pipeline, enabling targeted human-in-the-loop review of uncertain social risk classifications.

A dedicated interface for community-based organizations to manage incoming referrals and report outcomes. Core functionality:

• Referral inbox with accept, decline, and waitlist actions
• Capacity management to update service availability in real time
• Outcome documentation with structured fields aligned to Gravity Project value sets
• Secure messaging with referring clinical teams while maintaining HIPAA compliance

This bidirectional engagement ensures CBOs remain active participants in the closed-loop referral ecosystem rather than passive recipients of unactionable faxes or phone calls.

An automated workflow that tracks a patient's journey from a positive social risk screening through to a confirmed connection with a community-based service provider. Unlike traditional open-loop referrals where the outcome is unknown, closed-loop systems verify service delivery through bidirectional data exchange.

• Key components: Electronic referral initiation, provider acknowledgment, status tracking, and outcome confirmation
• Standards: Uses HL7 FHIR and CDS Hooks for EHR integration
• Impact: Reduces referral leakage by up to 40% compared to paper-based processes

A Fast Healthcare Interoperability Resources resource used to represent a specific, screened social risk finding in a standardized, exchangeable format. This resource enables seamless transmission of SDOH data between EHRs, community information exchanges, and referral platforms.

• Structure: Captures the screening tool used, the coded finding, the patient context, and temporal metadata
• Example: A food insecurity score of 2 on the Hunger Vital Sign screener, coded with a LOINC answer list
• Interoperability: Conforms to the HL7 FHIR SDOH Clinical Care Implementation Guide for cross-system exchange

The computational process of converting a patient's address into geographic coordinates to link their record with area-level social risk indices and community resource data. Accurate geocoding is foundational to resource linkage platforms that match patients to nearby services.

• Process: Address parsing, standardization, and matching against reference datasets like TIGER/Line
• Outputs: Latitude/longitude coordinates, census tract FIPS codes, and neighborhood-level indices
• Precision: Rooftop-level geocoding enables distance-based sorting of available community resources