Closing the Referral Loop in Social Prescribing: From Referral to Accountable Community Connection in Viet Nam
IMPLEMENTATION & PRACTICE
Closing the Referral Loop in Social Prescribing: From Referral to Accountable Community Connection in Viet Nam
Category: Implementation & Practice
A referral is easy to count; a connection is harder to know. A clinician, social worker or navigator may identify a social need, recommend a community resource and record that a referral was made. From the organization's perspective, the task can appear complete. From the person's perspective, however, almost everything that matters may still be ahead. Did the receiving organization actually receive the referral? Could it accept the person? Did anyone make contact? Was the support suitable and accessible? Did a meaningful connection occur? If it did not, did anyone notice?
This distinction matters because social prescribing is not simply about moving information from healthcare to the community. Its practical value depends on whether people have a realistic opportunity to connect with appropriate support. Recent international evidence suggests that social prescribing is shaped by relationships, navigation, cross-sector coordination, community capacity and local implementation conditions rather than referral mechanisms alone. Fragmented pathways, workforce pressures, limited community-sector capacity and weak coordination remain recurring implementation challenges.
For Viet Nam, where social prescribing is still emerging rather than operating through an established national model, this raises a practical question: How do we move from recording that a referral was sent to knowing whether an appropriate community connection actually occurred?
Referral is not the same as connection
The language used around social prescribing can make the pathway sound more straightforward than it is. “Refer to a community service” may describe very different actions. A healthcare professional might give someone the name of a local activity. A navigator might help them make a telephone call. An organization might electronically send information to another service. In a more supported pathway, someone may remain involved until the receiving organization has responded and the person has had a realistic opportunity to make contact.
These approaches should not be assumed to be equivalent. Simple signposting may be entirely appropriate for someone who knows what they want, can navigate independently and needs little additional support. Another person may need more active navigation because of disability, low confidence, transport difficulties, language barriers, financial constraints, limited digital access, cognitive problems, caregiving responsibilities or the complexity of the services involved. The objective is not to turn every suggestion into an intensive referral. It is to match the level of navigation to the person's circumstances and avoid creating the appearance of support when no usable connection has actually occurred.
This is particularly relevant in Viet Nam. Community support may come from formal organizations, social services, local associations, voluntary or civil-society organizations, clubs, faith or neighborhood networks, rehabilitation and physical-activity programs, older-person groups and many other forms of community resource. Their structure, governance, capacity and ability to receive formal referrals may vary substantially. A pathway designed as though every community resource operates like a healthcare provider is unlikely to work.
The accountable handover: a useful implementation idea, not an established standard
A timely contribution to this discussion appeared in September 2026 in The Lancet Regional Health – Western Pacific. Writing from primary care in Japan, Yusuke Shono proposed a closed referral loop for social prescribing. The proposal included four elements: the clinician recognizes the social need and obtains the person's agreement to proceed; a specific person or team receives the referral rather than the person simply being given a leaflet; the receiving organization communicates acceptance, deferral or refusal; and when connection fails, a designated person follows up, considers an alternative and provides feedback.
The importance of this proposal lies partly in its caution. The author explicitly states that these are not established requirements, and the model has not been shown to improve outcomes in Japan. It is an implementation proposal that requires testing. The paper also recognizes that receiving organizations would need adequate staffing and sustainable funding if they are expected to coordinate referrals and provide follow-up.
That distinction matters for Viet Nam. A closed referral loop should not be presented as a new international standard that Vietnamese organizations simply need to adopt. The more useful lesson is the question behind it: once a social need has been recognized and a community connection has been offered, can the pathway tell what happened next? That is a question worth testing.
What might an accountable connection look like in practice?
For an early Vietnamese pilot, a closed loop can be understood as a series of observable transitions rather than a rigid workflow. A person is first identified as someone for whom community-connected support may be relevant. The opportunity is discussed rather than imposed, and the person's willingness to proceed is established. If active navigation or referral is appropriate, the destination should ideally be identifiable. That may be a named organization, service, team or contact point that has agreed to receive the type of referral being made. Any personal information shared should be sufficient for the intended purpose but no broader than necessary.
The next important step is referral disposition, in practical terms, what happened to the referral. The receiving organization might accept it, determine that the person is not eligible, report that capacity is temporarily unavailable, request appropriate additional information or suggest an alternative resource. Then comes actual contact. Was the person reached? Was the intended support available and accessible? Did the person decide to participate? If the connection did not occur, was this because the person declined, could not be contacted, faced financial or transport barriers, found the resource unsuitable, encountered accessibility problems or experienced another obstacle?
Someone also needs to know what happens when a connection is unsuccessful. That does not mean repeatedly pursuing people until they participate. People remain free to decline community support. It means being able to distinguish an informed choice not to proceed from a referral that simply disappeared because nobody knew it had failed. That is the practical purpose of closing the referral loop.
Accountability should follow the task, not make one organization responsible for everything
The word “accountable” needs to be used carefully. Closing a referral loop should not mean that the referring clinician remains indefinitely responsible for resolving every social problem, nor should it mean that a community organization assumes clinical responsibility simply because it accepted a referral.
Social prescribing crosses organizational and professional boundaries. Accountability should therefore attach to defined actions and transitions, rather than to vague ownership of the person's entire situation. A healthcare professional may remain responsible for clinical care while a navigator supports a community connection. A community organization may determine whether it can provide the activity or service it offers without becoming responsible for clinical assessment or treatment outside its role. If a significant safety or clinical concern becomes apparent, the pathway should specify how that concern is escalated to an appropriate professional service.
An accountable handover should therefore not automatically be understood as a legal transfer of all responsibility from one organization to another. In an early Vietnamese model, it is more useful to think operationally: at each important transition, someone should understand what action is expected, what happens when that action cannot be completed and where the issue goes next. This is particularly important where healthcare, professional social work and community navigation intersect.
The receiving community organization needs to help design the pathway
Healthcare organizations can easily design referral systems from the perspective of the sender. A form is developed, eligibility criteria are written and professionals are encouraged to refer. The community sector is then expected to absorb whatever arrives. That approach is unlikely to be sustainable. Evidence from the Western Pacific shows substantial variation in how social-prescribing models are organized and identifies limited resources and fragmented referral systems among important implementation challenges. Broader international evidence similarly highlights community-sector capacity, workforce pressures, coordination and funding as important conditions for implementation.
Closing the referral loop therefore begins before the first referral is sent. Community partners need to help determine what types of referral they can reasonably receive, what eligibility or participation conditions apply, what information is genuinely required, how current capacity will be communicated and what level of feedback is feasible.
Not every community resource needs to become part of a formal referral network. A walking group, library activity, neighborhood initiative or other informal community asset may have neither the infrastructure nor the reason to receive identifiable health information. In these situations, supported signposting or navigation may be more appropriate than a formal electronic referral. The pathway should fit the community resource rather than forcing every community asset into the administrative structure of healthcare.
Do not confuse useful feedback with unnecessary surveillance
Closing the loop creates another tension. The more a healthcare organization wants to know about what happened after referral, the easier it becomes to collect or exchange more personal information than the pathway actually requires. A healthcare provider may be interested in whether someone attended an activity, how often they participated, what they discussed and why they later stopped. But information being interesting for evaluation does not automatically mean it is necessary to collect or return it to healthcare.
For many pathways, a limited status may be sufficient: referral received, person contacted, connection made, person declined, service unavailable, referral unsuitable or further follow-up required. A clinical team does not necessarily need detailed information about what a person does within a community group.
This is especially important under Viet Nam's current personal-data framework. Law No. 91/2025/QH15 on Personal Data Protection has been in force since 1 January 2026. Article 26 provides that the collection and processing of personal data relating to health require the data subject's consent, except in the circumstances specified in Article 19(1). Decree No. 356/2025/ND-CP, also effective from 1 January 2026, includes health status among categories of sensitive personal data.
Where identifiable information moves between a healthcare organization, navigator and community organization, the parties therefore need to understand what information is necessary, why it is being processed, what legal requirements apply, what consent is required where applicable, who should have access, how the information will be protected and how long it should be retained. Depending on the organizations involved and how data are processed or transferred, additional obligations under the Law and Decree may also apply. A responsible closed-loop pathway should therefore not aim to move as much information as possible. It should aim to move only the information that is necessary, proportionate and lawful for the intended connection and follow-up.
Keep the person at the center of the loop
Accountability between organizations is important, but social prescribing should not become an administrative exchange that happens around the person rather than with them. The person should understand what is being proposed, where relevant information is going and what they can reasonably expect to happen next. They should know whether they are expected to contact the community organization themselves or whether someone will contact them, and they should know what to do if nothing happens.
This may appear simple, but unclear expectations can turn a technically completed referral into a practical failure. The healthcare organization may believe the community organization will call. The community organization may expect the person to initiate contact. The person waits for a call that never arrives.
Good pathway design makes these expectations explicit while preserving choice. Someone agreeing to explore community support has not committed to participating indefinitely. After learning more about an activity or organization, they may reasonably decide that it is not right for them. That should not automatically be classified as failure. The more useful distinction is between choice and system failure: “the person understood the option and chose not to proceed” tells the system something very different from “nobody knows what happened after the referral was sent.”
Failed connections can be valuable implementation data
One of the most useful functions of a visible referral pathway is that implementation problems become easier to identify. If referrals repeatedly fail because a community program has no capacity, additional referral training for clinicians is unlikely to solve the problem; the problem is capacity. If people agree to referrals but rarely respond to telephone contact, the communication method may be inappropriate, the pathway may have been poorly explained or people may not recognize the organization contacting them.
Geography can matter as well. If people from one area connect successfully while those living farther away rarely participate, transport or local availability may be limiting access. If people with hearing impairment, limited digital access or lower health literacy are disproportionately lost before connection, the pathway may have an accessibility or equity problem rather than a motivation problem.
Without information about what happens after referral, these patterns can remain invisible while referral numbers continue to rise. A failed connection can therefore be more than a negative outcome. Properly understood, it can become implementation data that shows where the pathway needs to change.
Measure what happens after the referral
The 2026 Japanese implementation proposal suggests examining process measures such as referral disposition, time to first contact, actual connection to support and feedback to the clinician, alongside feasibility and patient outcomes. These are useful ideas for evaluation, not a validated indicator set that Viet Nam should simply adopt.
An early Vietnamese pilot could examine the pathway from the perspectives of the person, navigator, referring service and receiving organization. Relevant questions might include: How many potentially eligible people were offered the pathway? How many agreed to proceed? How many referrals reached the intended organization? How many were accepted, deferred or declined? How many people were contacted? How many made an initial connection? How many referrals remained unresolved?
Reasons matter as much as proportions. “Person declined,” “unable to contact,” “resource at capacity,” “not eligible,” “access barrier,” “referral inappropriate” and “alternative support arranged” should not all disappear into one category of unsuccessful referral. Timing can also reveal implementation problems. A referral that is eventually accepted but results in first contact several weeks later may technically close while still failing to provide timely navigation. Appropriate timelines will vary by service and level of need, so an early pilot should learn what is workable rather than impose a universal target before local experience exists.
Equity should also be considered where relevant, proportionate and lawful. Connection patterns may differ according to factors such as disability, location, digital access, age or socioeconomic barriers. The purpose is not to collect every possible demographic variable, but to identify whether important groups are systematically less likely to move through the pathway.
The community side deserves equal attention. How much staff or volunteer time does receiving and responding to referrals require? How frequently are referrals unsuitable? Can the organization realistically provide the requested feedback? Has healthcare created additional administrative work without contributing resources to support it? A pathway is not successful simply because the sender's dashboard looks good.
Technology can support visibility, but it cannot create accountability on its own
Digital systems can help make important transitions visible. They may record when a referral was sent, acknowledge receipt, display status, generate reminders and support follow-up. A 2026 formative evaluation in U.S. community health centers, not a social-prescribing study, but relevant to clinic-community coordination around social needs, illustrates both the potential and the limitations of this approach. The study found problems with referral documentation, fragmented information across EHR modules and referral systems, insufficient training, interoperability and workflow integration, while also highlighting the importance of relationships and infrastructure on the community-organization side.
The lesson for Viet Nam is not that a particular U.S. platform should be reproduced. It is that technology can only support a referral pathway whose underlying responsibilities and information flows already make sense. Technology cannot decide who is responsible when a community organization has no capacity. It cannot determine whether it is appropriate to ask an informal group to return detailed personal information. It cannot replace the conversation needed when a person is uncertain about participating, and it cannot resolve unclear professional boundaries.
For an early pilot with relatively few participants, an appropriately governed secure tracker may be more useful than a sophisticated platform. Building technology before understanding what statuses, responsibilities, escalation processes and information flows are genuinely required risks digitizing an unclear workflow. The important question is therefore not, “Do we have a referral platform?” It is: Can we see the important transitions in the pathway, and can somebody act when the pathway stalls?
Existing Vietnamese professional frameworks still apply
At present, Viet Nam does not have a dedicated national legal framework that specifically establishes social prescribing as a distinct profession or service model. That does not mean a community referral pathway sits outside existing professional regulation.
Decree No. 110/2024/ND-CP on Social Work, effective since 15 October 2024, regulates social work, social-work practice and related professional requirements. Under Article 47, from 1 January 2027, people practicing social work must hold a social-work practice registration certificate in accordance with the Decree.
For hospitals, Circular No. 51/2024/TT-BYT, effective from 1 March 2025, regulates social-work services and processes in medical examination and treatment establishments licensed to operate in the form of hospitals. Its provisions include activities such as assessment of psychological and social risks and needs, emergency support, connection and referral to appropriate services, intervention planning, case management and intersectoral coordination. Circular No. 29/2026/TT-BYT, effective from 25 August 2026, further regulates social-work practice and the updating of social-work knowledge.
These instruments do not create a Vietnamese social-prescribing profession or establish social prescribing as a national pathway. They do mean, however, that organizations, particularly hospitals, need to examine whether particular activities assigned to navigators overlap with regulated social-work practice or other professional responsibilities.
The same principle applies when closing a referral loop. A navigator may help determine whether a community connection occurred without assuming clinical or professional social-work responsibilities that sit elsewhere. A community organization may acknowledge whether it can receive someone without becoming responsible for that person's clinical management. Accountability should clarify professional boundaries, not erase them.
What could an early closed-loop pilot in Viet Nam look like?
A Vietnamese organization does not need a comprehensive citywide referral network before testing this approach. An early pilot could begin with one clearly defined population, a manageable range of needs and a small number of community partners willing to co-design how connections will work.
Before referrals begin, participating organizations could agree on what constitutes an appropriate referral, which resources can receive formal referrals and which are better suited to signposting, what minimum information is required, who receives it, how receipt is acknowledged where feasible, how the person will be contacted, what happens when a resource cannot help, what situations require professional escalation and what limited information should return to the navigator or referring service.
Early cases should receive relatively close observation. The aim is not to make every pathway end in participation but to understand where and why connections succeed or fail. After an initial period, the pilot may discover that referral criteria need adjustment, that a community partner needs less or different information, that the original follow-up process creates too much workload, that people prefer a different contact method or that certain resources cannot reasonably participate in a formal referral system. These findings should lead to redesign rather than being hidden within an overall connection rate.
As relationships mature, some parts of the pathway may become lighter. People who are comfortable navigating independently may need little follow-up, while stable partnerships may require less manual coordination. Those efficiencies should emerge from real implementation experience rather than being assumed from the beginning.
Do not close the loop by shifting the burden
There is one important risk. A closed referral loop is attractive from the healthcare perspective because it appears to provide certainty: send a referral, receive a response and record an outcome. But every acknowledgement, status update, telephone call and follow-up request creates work somewhere.
If that work simply moves from hospitals or clinics to under-resourced community organizations, the pathway has not solved fragmentation; it has redistributed the burden. The Japanese implementation proposal explicitly recognizes that accountable coordination and follow-up would require adequate staffing and sustainable funding on the receiving side. Wider international evidence makes the same broader point: community capacity, workforce availability, relationships and funding are central implementation conditions.
For Viet Nam, responsible implementation therefore requires asking not only, “Can healthcare know what happened to the referral?” but also, “What does providing that information require from the community organization?” Sometimes a formal closed-loop arrangement will be appropriate. In other situations, supported navigation or signposting with much lighter feedback may be preferable. Different community resources may need different models, and that variation is not necessarily a weakness.
Close the loop around meaningful connection, not administrative completion
The purpose of social prescribing is not to produce more referrals. It is to help people connect with appropriate forms of community support when those connections may contribute to health, well-being, participation or everyday life.
Referral completion should therefore not be defined simply as pressing “send.” A responsible pathway needs enough visibility to distinguish a genuine community connection from a referral that disappeared, a person's informed decision not to participate from a system that failed to reach them, and limited community capacity from poor referral practice.
For Viet Nam, this does not require immediately building a national closed-loop referral system. A more appropriate next step is to test whether community connections can become visible, accountable and learnable without over-medicalizing social needs, overloading community organizations or sharing more personal information than necessary.
The implementation question is therefore not simply “Was the person referred?” It is:
Did the person have a realistic opportunity to reach appropriate support, did the organizations involved understand what happened, and did someone know what to do when the connection failed?
That is the difference between recording a referral and building an accountable community connection.
References
Shono Y. Completing the referral loop: accountable handovers for social prescribing in Japan. The Lancet Regional Health – Western Pacific. 2026;74:101980. doi:10.1016/j.lanwpc.2026.101980.
Kisa A, Kisa S. Models, implementation, and reported outcomes of social prescribing interventions: a scoping review. Frontiers in Public Health. 2026;14:1871347. doi:10.3389/fpubh.2026.1871347.
Lwin KS, Wong MSJ, Tan MH, et al. Organization and implementation of social prescribing in the Western Pacific Region: a scoping review. The Lancet Regional Health – Western Pacific. 2026;67:101714. doi:10.1016/j.lanwpc.2025.101714.
World Health Organization Regional Office for the Western Pacific. A toolkit on how to implement social prescribing. Manila: WHO Regional Office for the Western Pacific; 2022.
Owens-Jasey C, Gunn R, Cook N, et al. Community Health Center Adoption of Enabling Technologies to Address Contextual Drivers of Health for Care-Managed Patients: Formative Evaluation. Journal of General Internal Medicine. 2026. doi:10.1007/s11606-026-10735-6.
Government of Viet Nam. Decree No. 110/2024/ND-CP on Social Work. Effective 15 October 2024.
Ministry of Health of Viet Nam. Circular No. 51/2024/TT-BYT on the implementation of social work in medical examination and treatment establishments. Effective 1 March 2025.
Ministry of Health of Viet Nam. Circular No. 29/2026/TT-BYT on social-work practice and updating social-work knowledge. Effective 25 August 2026.
National Assembly of Viet Nam. Law No. 91/2025/QH15 on Personal Data Protection. Effective 1 January 2026.
Government of Viet Nam. Decree No. 356/2025/ND-CP detailing certain articles and measures for implementation of the Law on Personal Data Protection. Effective 1 January 2026.