For health and human service (HHS) organizations, a referral is more than a handoff; it is a critical opportunity to move a client from crisis to stability. However, the fragmented nature of our current systems often forces vulnerable individuals to act as “system integrators,” navigating a fractured landscape alone. When these connections fail, the consequences are documented: poorer health outcomes, increased family stress, and diminished mental well-being.
To address these gaps, many states and municipalities are investing in HHS referral networks. These are collaborative arrangements designed to manage the entire lifecycle of a referral. But as these systems increase in number, a vital question remains: what actually makes a network effective?
Researchers at Northwestern’s Network for Nonprofit and Social Impact (NNSI) have released a new state-of-the-evidence report, Bridges to Resolution, led by Project Investigator Michelle Shumate and a team of contributing scholars from UIC, UC Berkeley, UCSF, the University of Pittsburgh, Washington University, and UIUC. The report’s central finding: success is not found in software alone. Rather, it results from deliberate interorganizational management and human infrastructure. Four patterns in the evidence indicate that design is the primary driver of whether a client actually receives help.
The Effectiveness Gap: Passive directories lose the majority of clients
One of the biggest factors separating networks that work from networks that don’t is whether an individual is expected to find help on their own or if there is someone to assist in the help-seeking process. Passive “information-only” models, like simple resource information without network infrastructure, yield assistance for roughly 25% of clients. In contrast, active models with centralized coordination and human navigation have achieved service receipt rates as high as 88%.
This is not a minimal difference; the gap distinguishes a network that mostly fails to provide help and one that successfully bridges an individual to the help they need. It suggests that simply directing someone to a list of services, without having anyone responsible for making sure a referral actually lands, shifts the burden of navigating a fragmented system entirely onto the individual seeking help.
The Power of Human Navigation
High-touch models where dedicated staff guide clients through every step are shown to remove logistical barriers and improve outcomes. Participants in a 2025 study of the Pathways model in Ohio had 43% lower adjusted odds of a low birth weight birth. This shows that navigation is not something that simply speeds up paperwork; it has the potential to change clinical outcomes.
Having a navigator who helps someone get to an appointment, understand complex forms, or explain the system, helps remove barriers that keep people from accessing the care they need and presents a strong case that navigator roles are core to the intervention, not an add-on.
The Fiscal Case
Well-designed networks not only help clients, but they can reduce costs. The Accountable Health Communities pilot found that Medicare and Medicaid clients who received navigation support saw total expenditure reductions of 3–7%, or roughly $375 to $1,100 per member per year.
What does this mean for funders and health systems? This is a promising lead that demonstrates unresolved social needs can be more costly to the healthcare system. Investing in referral networks and navigation support can help reduce healthcare spending while improving access to needed resources. For funders and health systems, this presents itself as a strong financial case for supporting programs that address social needs alongside healthcare services.
The Fragility of Success
Referral effectiveness is directly linked to resource availability. In Durham County, North Carolina’s NCCARE360 pilot, service receipt rates reached 88% when funds were available for community organizations and navigators, but plummeted to 30% once that funding ended. The shift from 88% to 30% highlights the importance of sustained funding in maintaining effective referral networks.
It strongly suggests that successful results and outcomes may depend on continued investment in community organizations and navigators. For leaders looking to scale these programs, this emphasizes the need to account for resources required and available to maintain their referral capacity.
Rethinking the “Digital Fix”
It is tempting to view referral networks as a “set-and-forget” technology. But as the research highlights, even the most sophisticated platform requires a “human connector” to verify that a referral was completed. Without this human infrastructure, we risk building a “Bridge to Nowhere,” a system that screens for needs but leads to unavailable or non-existent services.
For leaders at the federal, state, and municipal levels, the path forward requires a shift in focus:
Design Before You Digitize: Establish network aims, scope, and governance before selecting technology platforms or intervention workflows.
Invest in People: Prioritize funding for “backbone staff” and navigators who manage the logistics technology cannot solve.
Design for Equity: Assess the administrative burdens placed on smaller, culturally specific providers to ensure they aren’t excluded.
Reality-Check Scope: Align the network’s reach with actual service availability to maintain credibility with the community.