Abstract
INTRODUCTION: The Social Care Network (SCN) is a payor-provider-system integrated social care referral model designed to address historical challenges of scalability and sustainability through structured partnerships with community-based organizations (CBOs) and incentives for referral tracking and service delivery. METHODS: To evaluate the effect of the SCN on completion of referral updates (ie, loop-closure), receipt of services, and medical costs and utilization, we conducted a quasi-experimental difference-in-differences analysis among insured adults referred to the SCN (8/2022-10/2024). Medical costs and utilization were compared between individuals who did and did not receive services. Program outcomes were compared between SCN and non-SCN CBOs. RESULTS: Of 2305 SCN CBO referrals, 85% were closed-loop versus 24% of 8288 non-SCN CBO referrals (P < .001); 27% of SCN referrals resulted in services received versus 17% of non-SCN referrals (P < .001). Receiving social care was associated with a $617 reduction in per-member-per-month medical costs (P < .001). Inpatient admissions declined by 26 per 1000 members per month (P < .001) and unplanned admissions by 9 (P = .002). CONCLUSIONS: These results suggest that a scalable, sustainable social care network can be implemented within a health system. Embedding community-based social care in value-based contracts aligns accountability across sectors, increases successful referrals, and reduces downstream medical costs.