Social care referral networks: Improving health in rural communities

Over the next decade, all 50 states will collectively receive $50 billion in federal funding to strengthen rural health systems and improve health outcomes in underserved communities. This funding is through the Rural Health Transformation Program (RHTP), which seeks to improve health outcomes for America’s rural communities. All states proposed initiatives in their RHTP applications to address health-related social needs such as food insecurity, housing insecurity, and community health worker models, underscoring the central role of social care in rural health transformation.

Indeed, more than two-thirds of state applications mention efforts to build infrastructure that would enable social care referral networks (SCNs)—systems that allow healthcare providers, payers, and public health workers to identify social needs and refer individuals to community-based services to meet those needs.¹Including references in Alaska, Arizona, Arkansas, Colorado, Connecticut, Hawaii, Indiana, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, New Hampshire, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Utah, Vermont, Virginia, Washington, West Virginia, and Wisconsin. Terminology for SCNs that states use in their RHTP applications varies, including “rural social care network,” “community wellness hubs,” “rural health innovation hubs,” “regional care networks,” “innovation hubs,” and more. For ease of reading, this article refers to all of the above as “social care referral networks” or SCNs. The question, then, is this: What can states learn from previous efforts to design SCNs to improve outcomes in rural communities?

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