EquiLoop™
The Closed-Loop Infrastructure Behind Social Prescribing
Track every health-related social need from screening through documented resolution. EquiLoop is the operational backbone of social prescribing, connecting community members to services, coordinating across partner networks, and proving outcomes to funders, all in one workflow.
Rural health hub deployment with a multi-partner ecosystem. Includes both clinical and social services referrals.
Screening alone doesn't improve outcomes
Most organizations can identify social needs. The challenge is what happens next: the coordination, tracking, and follow-up that determines whether people actually get help.
Referrals vanish after the handoff
You send a referral to a partner organization. Then what? There's no system to track whether the individual was contacted, served, or fell through the cracks.
You can count referrals, not completions
Funders want completion rates, time-to-service, and barrier analysis. Most programs can report how many referrals were sent, not how many were resolved.
Follow-up is manual and inconsistent
Care coordinators track referrals in spreadsheets, sticky notes, and memory. When caseloads grow, follow-up drops off and people fall through.
Everything between the screening and the outcome
EquiLoop provides the infrastructure that turns a one-time screening into an ongoing, trackable care coordination workflow.
Digital Enrollment & Consent
Mobile-first, multilingual intake that replaces paper forms. Configurable to any program's eligibility and consent requirements.
SDoH Screening & Needs Assessment
Recurring assessments across food, housing, transportation, behavioral health, utilities, and more. Not one-and-done, but part of an ongoing care cycle.
Closed-Loop Referral Tracking
Every referral tracked from initiation through documented resolution. Program matching surfaces the programs that address each identified need at intake, and partners receive, accept, act on, and confirm referrals within a shared system.
Automated Follow-Up & Escalation
Configurable follow-up via SMS and email. Aged referrals trigger escalation alerts at 7, 14, and 30+ days, so nothing ages without visibility.
Dashboards & Reporting
Role-based dashboards for operations, leadership, and funders. Exportable KPI packs on weekly, monthly, and quarterly cadence, audit-ready out of the box. Funder reports can include participant stories with identifying details removed.
Grant Tracking & Deliverables
Award amounts and budget line items held alongside the work they fund. Deliverable deadlines tracked with reminders, so nothing a funder is waiting on arrives late. See how this works for grant-funded programs.
Six things every program gets
Capabilities describe what the platform does. These describe what your program experiences, operationally and over time, when EquiLoop is the infrastructure behind it.
A closed loop, not just a referral
Your existing partners become a governed, tracked workflow. Every referral has a status, an owner, and a path to documented resolution, with escalation at 7, 14, and 30 days.
Every social driver tracked to resolution
Food, housing, transportation, utilities, benefits, and behavioral health move through a workflow instead of sitting as checkbox fields. You can report how many needs were resolved, not just screened.
A network that gets stronger as it grows
Each partner joins with defined routing and response expectations, so adding partners extends reach and resolution speed without the same increase in coordination work.
Reporting built in, not assembled at deadline
Each service is recorded once and feeds the referral, the follow-up, and the report. Funder-ready exports, role-based dashboards, and equity analytics come from the workflow itself, so the documentation already exists when reporting time comes.
A team that stays for the life of the program
Training for new hires, quarterly outcomes reviews, and help onboarding new partners are part of the engagement, not add-ons after go-live.
An evidence base for your next funding ask
Documented completion rates, time-to-service, and equity reach, alongside award budgets and deliverable deadlines, position a program for renewal and expansion funding, and for grants that require proof of prior performance.
The programs EquiLoop is built for
Each program type has its own page with the workflows, reporting, and partners that fit it.
Rural Health Transformation
Closed-loop referrals, intake workflows, KPI reporting, and workforce development for RHT programs
Tribal Health Programs
A shared front door across clinical and community programs, with data that belongs to the Tribe
Local Health Departments
Population-level SDOH visibility, multi-program reporting, and coordination across the partners in your jurisdiction
FQHCs
UDS reporting and value-based care, alongside the EHR you already run
AHECs
Multi-county coordination, shared intake, and closed-loop referrals across clinical and community partners
Community-Based Organizations
Funder-ready reporting, grant tracking, and referral confirmation back to partners
Grant-Funded Programs
Award budgets, deliverable deadlines, and funder reports built from the work itself
School-Based Health Centers
Enrollment, consent, PHQ-2 and PHQ-9 screening, follow-up coordination, and program reporting, with records handling set up for FERPA, HIPAA, or both
Health Hubs & Community Centers
Shared intake, navigation, and closed-loop referrals across every partner behind one front door
Mobile Health & Mobile Clinics
Field intake, partner handoff, and follow-up after the unit moves on
Same-day resolution: from screening to restored water service
A community member in Western Maryland had their water shut off for over a week, creating immediate health risks. Through EquiLoop, a community health worker identified the issue during a routine SDoH screening. The referral was routed to the Department of Social Services and acted on the same day.
Water service was restored by 1 PM. The need was identified, routed, and resolved the same day, with the outcome confirmed and recorded in the closed loop.
See more impact stories →Turn Referrals Into Documented Outcomes
From screening to resolution, EquiLoop gives your team the infrastructure to coordinate care, track outcomes, and report impact, in days, not months. One flat subscription for your organization, with no per-seat or usage charges.
Not ready to book? Send us a note →