Bridges to Resolution highlighted that even a well-designed HHS Referral Network can become a “Bridge to Nowhere,” a system that screens for needs but can’t actually deliver on them. That risk exists because of the gap between social need and healthcare service delivery. The two areas are deeply intertwined, yet the agencies that provide health and human services operate as a fragmented system.
As millions of Americans struggle to meet basic needs, they must navigate social services on their own. Individuals face barriers at every step, including limited resources, knowledge, and access to formal support. Design gets a network off the ground. But design alone doesn’t keep it running once real clients, real caseloads, and real budget cycles hit the system. Often, networks fracture in the day-to-day friction between a hospital’s clinical workflow and a Community-Based Organization’s (CBO) front-line reality.
Healthcare systems and CBOs operate with different funding models, cultures, and workflows, and that mismatch is where most implementation failures start. Drawing on the new companion guide, here are the four most common barriers networks run into, along with practical fixes for each.
CBO Capacity Strain
CBOs often operate with far fewer resources than their healthcare partners. Many rely on short-term grants and donations, have limited administrative capacity, and struggle to recruit and retain frontline staff.
These challenges become especially acute when healthcare systems expand social needs screening. A hospital may identify hundreds of patients who need housing, food, or transportation assistance while organizations receiving those referrals may lack the staff, funding, or infrastructure needed to meet the increased demand. When capacity is strained, service bottlenecks emerge, referrals go unmet, and clients may lose trust in the system.
Recommendation: Healthcare systems should treat CBO capacity as a design constraint rather than an afterthought. Networks should invest in social service partners through funding for navigator roles, shared technology platforms, and other resources needed to absorb referral volume.
Power Imbalances
Healthcare organizations often enter referral networks with larger budgets, more staff, and greater political influence than their CBO counterparts. While healthcare participation can bring valuable resources and credibility to a network, it can also leave community priorities positioned second to healthcare priorities.
As a result, network processes may center clinical workflows without fully accounting for the realities frontline social service providers face. Over time, this can reduce buy-in from CBO partners and weaken the collaborative relationships that make referral networks effective.
Recommendation: Build shared governance from the start. Engage CBOs during the design process, establish clear decision-making structures, and consider using a neutral convener, such as a local United Way chapter, to help balance perspectives and priorities.
Information Decay
Resource directories become outdated quickly. Service providers change operating hours, eligibility requirements shift, programs lose funding, and new services emerge. Information that was accurate a few months ago may no longer reflect what is available today.
When resource information is outdated, referrals begin to fail. Clients may be directed to organizations that no longer provide the services they need, encounter unexpected eligibility restrictions, or struggle to connect with the correct provider. These breakdowns frustrate clients and make providers less likely to trust the referral process.
Recommendation: Assign responsibility for directory accuracy to a dedicated role or team and establish a regular process to validate provider information rather than waiting for referral failures to surface problems.
Cultural Friction
Healthcare systems and CBOs often approach service delivery from very different perspectives. Clinical environments typically emphasize documentation, standardization, and clearly defined workflows. In contrast, human service organizations often prioritize flexibility, relationship-building, and responding quickly to immediate client needs.
These differences can create friction even when partners share the same goals. If left unaddressed, these differences can erode trust and make cross-sector collaboration more difficult.
Recommendation: Use Memorandums of Understanding (MOUs) as practical operating guides rather than simply legal agreements. Clearly define roles, responsibilities, referral processes, and escalation pathways so staff understand how to work through situations where organizational norms differ.
This guide is designed for state, municipal, and nonprofit leaders tasked with designing, implementing, and evaluating an integrative care system. It focuses on day-to-day network management, recommendations to overcome implementation barriers, and detailed strategies for performance monitoring and improvement.
With millions of Americans struggling to navigate the system, Health and Human Service Networks provide critical infrastructure to connect individuals to the services they need. However, the sustained cross-sector collaboration that these networks require poses both implementation and evaluation challenges. Implementing and Evaluating HHS Referral Networks: A Companion Guide to Bridges to Resolution provides comprehensive guidance to address these challenges, enabling leaders to establish a network that works.
Download the report here to turn your network design into a practical reality.
