Stronger Together: How a Nonprofit Health System Partnered with Community Organizations to Improve Patient Health Outcomes at Scale

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Background

Inova is the largest nonprofit health system in Northern Virginia, delivering care to more than one million unique patients annually across hospitals, specialty practices, emergency departments, and outpatient centers. Consistently ranked and recognized as a national healthcare leader in safety, quality, and patient experience, Inova’s world-class care is made possible by the strength and breadth of its network, 26,000 team members, technology, and innovation.

 In 2023, Inova partnered with Unite Us to launch a system-wide strategy focused on addressing social drivers of health (SDOH) through technology-enabled care coordination and community partnerships. Today, Inova helps facilitate a regional network of community-based organizations working together to improve whole-person health. 

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Challenge

Like many nonprofit health systems, Inova serves a diverse patient population with complex needs that directly affect health outcomes. While many community resources already existed across Northern Virginia, organizations often relied on varied and sometimes inconsistent referral mechanisms. At the community level, organizations were working hard to meet local needs, but often in isolation, without a consistent way to coordinate referrals, track outcomes, or measure collective impact.

Within the health system, care teams regularly identified patients with unmet non-medical needs, but workflows relied on static resource lists, manual phone calls, emails, or even faxes. These approaches were time-consuming, often outdated, and rarely provided visibility into outcomes. Additionally, studies evaluating SDOH screening and referral interventions have shown that while resource lists are often shared, a notable proportion of patients do not successfully connect to services without enhanced navigation or follow-up. As SDOH screening expanded in 2021, teams raised a clear concern: if we’re asking these questions, we must be able to do something about the needs.

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Solution

Inova partnered with Unite Us in 2023 to support a technology-enabled approach to whole-person care through Unite Virginia, a statewide coordinated network that connects healthcare teams and community-based organizations through a shared, closed-loop referral system. The platform enabled the work, but the real shift came from community partnership, shared ownership, and operational commitment across the region.

By combining trusted community relationships with a robust closed-loop electronic referral system, Inova helped build a collaborative model that streamlines how patients’ needs are identified, addressed, and continuously met and monitored over time. Key components of the solution included:

 

1. Community Partnership and Network Engagement

Recognizing that strong relationships drive success, Inova prioritized collaboration and shared goals with community-based organizations, including:

Orienting partners to a shared community strategy: Inova helped align organizations around a broader vision of supporting whole-person care and improving health outcomes through better care coordination. Just as importantly, Inova reinforced its commitment to success  by putting its own clinics and programs on the platform, showing partners that the health system was participating alongside them, not simply “sending work outward.” 

Outreach, onboarding, and training: Inova invested time in engaging new and existing partners in the network through structured onboarding and training. The goal was to reduce friction and make participation sustainable for organizations with limited capacity. Inova also supported partners with toolkits to help raise awareness and engagement, recognizing that community organizations are often the most trusted connectors.

Supporting network development through philanthropic partnerships: Inova also engaged philanthropic support to strengthen network development efforts, including a partnership with 100 Women Strong, a philanthropic organization in Loudoun County that supported the creation of a cohort of nonprofits that received training and onboarding assistance to join the platform together. This reinforces that sustainable community collaboration requires investment and shared accountability, not just technology.

 

2. Leveraging Technology

Inova leveraged Unite Us’ closed-loop referral system to support a broader community-wide goal: timely, coordinated, closed-loop referrals to community services, with deeper visibility into outcomes. Key ways technology supported this work included:

Closed-loop referral workflows: Instead of relying on phone calls, emails, faxes, and inconsistent processes, care teams can send referrals directly to community partners and track progress through to resolution and outcomes. Community-based organizations can also send referrals to each other, improving follow-through and transparency across organizations. 

EHR integration and automated workflows: Integrating the Unite Us closed-loop referral system directly into clinical workflows within Inova’s EHR helped care teams connect patients to community resources more efficiently at the point of care. 

Flexible workflows based on patient need and team capacity: Inova uses different approaches depending on patient need and context, ranging from sharing resource information to sending closed-loop referrals when deeper coordination is required. This flexibility supports whole-person care and allows for different approaches based on the patient’s health-related social needs and unique circumstances.

Data and reporting: Inova uses reporting and analytics to monitor network performance and growth, review rejected or stalled cases, identify service utilization patterns to inform more targeted interventions, and continuously refine workflows. Network data is incorporated into Inova’s community health improvement plans, aligning strategy to execution as Inova continues to foster an accountable community network that meets the critical needs of their patients.

 

3. Generating Buy-In from the Health System to Catalyze Community Change 

Success required more than community participation; it also required health system commitment and buy-in across departments, leaders, and frontline teams. Inova implemented a structured rollout approach, centralized training resources, supported ongoing adoption efforts, empowered internal champions, and aligned the work to measurable KPIs. By connecting workflow efficiency to improved patient outcomes, Inova was able to sustain adoption and build long-term support from stakeholders.

 

4. Growing and Scaling a Quality Network of Partners

For Inova, scaling the network meant focusing on quality and accountability, not just expanding participation. Through regular rejection audits and “needs action” reviews, Inova analyzes referral trends to identify and fix gaps such as eligibility misalignment or unclear program criteria. These insights inform targeted training, clearer partner listings, and workflow adjustments, ensuring referrals are appropriate, actionable, and aligned with community partner capacity.

Just as importantly, Inova remains actively engaged in the broader nonprofit ecosystem. By participating in community conversations, aligning efforts with Community Health Needs Assessment (CHNA) priorities, and contributing to communities of practice, Inova ensures the network reflects real community context and shared goals.

This combination of operational discipline and authentic partnership strengthens trust across the network and supports a coordinated, continuously improving system of care.

 

Impact

Through sustained community collaboration and a closed-loop referral system, Inova has driven measurable impact across patients, care teams, and partners.

Key Results

Since launching its system-wide SDOH strategy, Inova has screened more than 1,000,000 patients for SDOH needs.

Recent screening data revealed clear opportunities for intervention and whole-person support:

• 39% of patients screened positive for stress
• 14% were at some risk for housing instability
• 14% experienced financial resource strain
• 6% were food insecure

Based on these identified needs*, 

• 7,292 Unite Us referred cases were created
• 5,512 cases were accepted by community partners (a 76% acceptance rate),
• 3,683 cases were closed as resolved (a 67% resolution rate).

In addition, partners sent: 

• 3,981 referrals to Inova clinics and programs
• 92% of referrals were accepted by Inova
• 2,831 cases were closed as resolved (a 68% resolution rate).

The median time to case closure was 10 business days. In addition, 257 community programs were shared across 871 resource lists, expanding patient visibility into available services. 

Top Service Type Categories:

• Physical Health (29%)
• Food Assistance (25%)
• Housing & Shelter (12%)
• Benefits Navigation (10%)
• Individual & Family Support (6%)

Beyond the numbers, Inova has strengthened community partnerships, improved access to essential services, and increased confidence among care teams. By pairing data-driven insights with authentic community collaboration, Inova has built a more accountable, responsive system of care that advances whole-person health across Northern Virginia.

*Data pulled from Unite Us Platform, date range April 1, 2023 – April 15, 2026

 

Lessons Learned

Inova’s experience offers practical insights for health systems seeking to build sustainable, community-centered care networks:

1. Technology is a tool, not the entire solution. A closed-loop referral system provides structure and visibility, but lasting results depend on trusted relationships, shared ownership, and strong leadership across the health system and community partners.
2. Start by listening and aligning around the community context. Sustainable adoption requires engaging both internal teams and community-based organizations early, understanding the local nonprofit ecosystem, and aligning efforts with broader priorities such as Community Health Needs Assessments (CHNAs).
3. Data drives credibility and informs strategy. Measuring ROI and sharing outcomes helps secure continued investment and executive support. It also helps identify areas where there may be gaps to inform future strategy. 
4. Engage motivated partners. Working with nonprofits to join the network and demonstrate effectiveness helped ensure sustainability. Partnering with philanthropy organizations and grant makers to show them the current and potential impact, and engaging them in creative solutions, was important in supporting these efforts.

As Inova continues advancing whole-person care across Northern Virginia, its focus remains on deepening community partnerships, improving patient outcomes, and using data-driven insights to guide future innovation. Underpinning this work is a shared belief that improving community health requires collective action from health systems, community-based organizations, and philanthropic partners, all working together toward lasting impact.

Visit www.inova.org and www.uniteus.com/demo to learn more about how community collaboration, technology-enabled care coordination, and shared accountability can drive whole-person care and improve health outcomes at scale.