VALLEJO SECTOR PAGE
Healthcare Closed-Loop Referrals in Vallejo
A practical referral-accountability framework for hospitals, clinics, behavioral health teams, and community partners preparing to confirm what happens after an authorized handoff.
PRELAUNCH: Operation Iron Gate is being developed as a North Bay Pilot. Public intake is not open, and this page does not promise placement or services. GATEHOUSE, our community platform and a smaller version of Operation Iron Gate, is open now: register on GATEHOUSE.
PLAIN-LANGUAGE DEFINITION
What a closed-loop healthcare referral means
A referral is not complete when information is sent. The loop closes when the receiving organization acknowledges the referral, responsibility is visible, the next action or barrier is recorded, and the sending team can see an appropriate status.
This can strengthen discharge and follow-up workflows without changing each organization’s eligibility, clinical, or service decisions.
THE SCREENING TOOL
The Accountable Health Communities screening tool
The Accountable Health Communities Health-Related Social Needs Screening Tool (AHC HRSN) is a 10-question screening tool from the Centers for Medicare & Medicaid Services. It is designed for clinics, emergency departments and hospitals to ask patients about needs that affect their health but sit outside the exam room. It covers five core areas, plus eight optional ones.
CORE AREA
Housing
Housing instability or poor housing quality.
CORE AREA
Food
Worry about food running out, or food that did not last.
CORE AREA
Transportation
Trouble getting to appointments, work or other daily needs.
CORE AREA
Utilities
Shut-off threats from the power, gas, oil or water company.
CORE AREA
Safety
Being hurt, insulted or threatened by someone.
ALSO IN THE TOOL
Eight optional areas
Financial strain, employment, family and community support, education, physical activity, substance use, mental health and disabilities.
A screen finds the need. It does not connect the person to help.
A positive screen produces a referral, and a referral is where many handoffs stop. If the receiving organization never confirms the person arrived, nobody knows whether the need was met. That is the gap closed-loop referral is built to close, using the four steps below: an authorized referral, confirmed receipt, a recorded action or barrier, and a status that reaches the sender.
Pathfinders for Hope is not affiliated with CMS and does not administer the AHC tool. Operation Iron Gate is a proposed handoff layer. It would not replace a screening tool or a clinic’s workflow, and the North Bay Pilot has not started, so there are no results to report. Referrals tied to the safety area would follow each organization’s own safety and privacy rules.
PLAIN-LANGUAGE PROCESS MAP
A four-step confirmed healthcare handoff
Each step names what partners should be able to confirm. This is a planning model, not a claim that the North Bay Pilot is live.
01 · SEND
Authorized referral
The sending team shares only the information needed for the receiving organization to act.
02 · ACKNOWLEDGE
Receipt is confirmed
The receiving team records that the referral arrived and identifies who owns the next action.
03 · RESPOND
Action or barrier is recorded
The receiving team records contact, an eligibility decision, a denial reason, or a capacity block.
04 · RETURN
Status reaches the sender
An appropriate outcome or next-action status returns so the handoff is not left invisible.
OUTCOME MEASURES
What healthcare partners can measure
These are definitions for future reporting. No verified pilot results are available yet.
MEASURE
Arrival rate
The share of authorized referrals that the receiving organization confirms it received.
MEASURE
Time to first contact
Elapsed time between referral receipt and the first documented outreach attempt.
MEASURE
Barrier visibility
The share of referrals with a documented denial reason, capacity block, or next step.
Questions for a healthcare workflow review
• Who is authorized to send the referral, and what consent or permission is required?
• Who acknowledges receipt, and within what operating window?
• Which statuses can be shared back without exposing unnecessary clinical or personal information?
• How are denials, no-response events, and capacity blocks categorized so partners can improve the pathway?
Prepare a real Vallejo referral workflow
Review the closed-loop referral standard, the No-Dead-End referral model, HMIS alignment, and the referral governance brief. Explore the North Bay Pilot Results Dashboard, housing and homelessness referral accountability, youth services referral tracking, or information for organizations.
The working room
Don’t fix referrals alone.
GATEHOUSE is where the agencies, hospitals, churches and neighbors working on referrals in Vallejo and Solano County talk it through. It is the part of Operation Iron Gate that is open today, and what members say decides what we build next.
Already a member? Log in
GATEHOUSEMember pass
OPEN NOW- Put your agency on the mapList your organization and post what you have open for Tonight.
- Ask the teamOpen Q&A with our team and peers who work the same handoffs.
- Report a dead endLog a referral that went nowhere and follow it to a fix.
- Follow the pilotPilot Updates as the North Bay Pilot is built. No results are claimed.