{"id":12516,"date":"2026-07-09T15:21:55","date_gmt":"2026-07-09T19:21:55","guid":{"rendered":"https:\/\/uniteustailstg.wpengine.com\/?p=12516"},"modified":"2026-07-30T11:15:25","modified_gmt":"2026-07-30T15:15:25","slug":"improving-patient-outcomes-with-nonprofit-health-system-inova","status":"publish","type":"post","link":"https:\/\/uniteus.com\/case-study\/improving-patient-outcomes-with-nonprofit-health-system-inova\/","title":{"rendered":"Stronger Together: How a Nonprofit Health System Improved Outcomes Through Community Partnerships"},"content":{"rendered":"

\"\"Learn how Inova, a nonprofit health system, implemented a system-wide social drivers of health (SDOH) strategy, aligned internal teams, engaged community partners, measured service-specific outcomes, and advanced whole-person health through technology-enabled care coordination.<\/span><\/h4>\n","protected":false},"excerpt":{"rendered":"

Learn how Inova, a nonprofit health system, implemented a system-wide social drivers of health (SDOH) strategy, aligned internal teams, engaged community partners, measured service-specific outcomes, and advanced whole-person health through technology-enabled care coordination.<\/p>\n","protected":false},"author":5,"featured_media":12620,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"footnotes":""},"categories":[108],"states":[],"topic":[86,96,88],"industry":[74],"series_name":[],"class_list":["post-12516","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-case-study","topic-healthcare","topic-partnership","topic-technology","industry-providers"],"acf":{"layout":"report","gated_page":{"":null,"title":"","featured_image":null,"description":"","form_title":"Fill out the form to download the white paper.","code_editor":"","title_2":"","description_2":"","embeds":null,"display_cta_button":true,"button_text":"Download the White Paper"},"columns":null,"download_page":{"document":""},"reports_component":{"components":[{"acf_fc_layout":"buttons","_acfe_flexible_layout_title":null,"_acfe_flexible_toggle":null,"action_buttons":[{"name":"Read the Case Study","style":"button-solid","link_type":"external","page_link":null,"link":"#background","icon":"down-caret","is_blank":false,"background_color":"","text_color":"","background_color_hover":"","text_color_hover":""}]},{"acf_fc_layout":"key_takeaways","_acfe_flexible_layout_title":null,"_acfe_flexible_toggle":null,"id":"","menu_label":"","header":"

Key Takeaways<\/h2>\r\n

In this case study, you\u2019ll learn how:<\/h3>\r\n\"\"Building community-centered networks<\/strong> supports whole-person care.<\/span><\/span>\r\n \r\n\r\n\"\"Connecting screenings to measurable action<\/strong> leads to timely, trackable follow-through.<\/span><\/span>\r\n\r\n\"\"Using data to strengthen network performance and demonstrate ROI<\/strong> enables continuous improvement and sustained executive alignment.<\/span><\/span>\r\n\r\n\"\"Aligning leadership, frontline teams, and community partners around shared goals<\/strong> drives collective impact at scale<\/span><\/span>","takeaways":null,"text":"","tiles":null},{"acf_fc_layout":"wysiwyg","_acfe_flexible_layout_title":null,"_acfe_flexible_toggle":null,"id":"background","wysiwyg":".<\/span>\r\n

Background<\/h2>\r\nInova<\/span><\/a> 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 <\/span>ranked and recognized<\/span><\/a> 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.<\/span>\r\n\r\n\u00a0<\/span>In 2023, Inova partnered with Unite Us to launch a system-wide strategy focused on addressing 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.<\/span>\u00a0<\/span>\r\n\r\n
\r\n\r\n \r\n

Challenge<\/h2>\r\n\"\"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, <\/span>organizations<\/b> often relied on varied and sometimes inconsistent referral mechanisms<\/b>. 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.<\/span>\r\n\r\nWithin 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<\/span> time-consuming, often outdated, and rarely provided visibility into outcomes.<\/b> Additionally, <\/span>studies<\/span><\/a> 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:<\/span> if we\u2019re asking these questions, we must be able to do something about the answers.<\/b>\r\n\r\n
\r\n\r\n \r\n

Solution<\/h2>\r\n\"\"Inova partnered with Unite Us in 2023 to support a technology-enabled approach to whole-person care through <\/span>Unite Virginia<\/span><\/a>, 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.<\/span>\r\n\r\nBy combining trusted community relationships with a robust closed-loop electronic referral system<\/a>, Inova helped build a collaborative model that streamlines how patients\u2019 needs are identified, addressed, and continuously met and monitored over time.<\/span>"},{"acf_fc_layout":"blockquote","_acfe_flexible_layout_title":null,"_acfe_flexible_toggle":null,"id":"","text":"\u201cAs a pediatrician, I value the closed-loop referral process because it connects families directly with trusted community partners instead of handing them a list of resources that may be outdated or unavailable. The referral process using Unite Virginia\/Unite Us helps ensure patients actually receive the support they need, while giving providers the confidence that no family will fall through the cracks.\u201d <\/span>\r\n\r\n\u2013 Henna Qureshi,<\/span><\/strong> DO, FAAP, Pediatrician, Inova Cares for Children<\/span>"},{"acf_fc_layout":"wysiwyg","_acfe_flexible_layout_title":null,"_acfe_flexible_toggle":null,"id":"background","wysiwyg":"Key components of the solution included:\r\n \r\n

1. Community Partnership and Network Engagement<\/span><\/h3>\r\nRecognizing that strong relationships drive success, Inova prioritized collaboration and shared goals with community-based organizations, including:<\/span>\r\n\r\n\"\"Orienting partners to a shared community strategy:<\/b> 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\u00a0 by putting its own clinics and programs on the platform, showing partners that the health system was participating alongside them, not simply \u201csending work outward.\u201d\u00a0<\/span>\r\n\r\n\"\"Outreach, onboarding, and training:<\/b> 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.<\/span>\r\n\r\n\"\"Supporting network development through philanthropic partnerships:<\/b> Inova also engaged philanthropic support to strengthen network development efforts, including a partnership with <\/span>100 Women Strong<\/span><\/a>, a philanthropic organization in Loudoun County that supported the creation of a <\/span>cohort of nonprofits<\/span><\/a> 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.<\/span>\r\n\r\n \r\n

2. Leveraging Technology<\/span><\/h3>\r\nInova leveraged Unite Us\u2019 <\/span>closed-loop referral system<\/span><\/a> 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:<\/span>\r\n\r\n\"\"Closed-loop referral workflows:<\/b> 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.\u00a0<\/span>\r\n\r\n\"\"EHR integration and automated workflows:<\/b> Integrating the Unite Us closed-loop referral system directly into clinical workflows within Inova\u2019s EHR<\/a> helped care teams connect patients to community resources more efficiently at the point of care.\u00a0<\/span>\r\n\r\n\"\"Flexible workflows based on patient need and team capacity:<\/b> Inova uses different approaches depending on patient need and context, ranging from sharing resource information<\/a> 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\u2019s non-medical needs and unique circumstances.<\/span>\r\n\r\n\"\"Data and reporting:<\/b> Inova uses reporting and analytics<\/a> 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.<\/span>\r\n<\/span>\r\n\r\n \r\n

\"\"<\/span>3. Generating Buy-In from the Health System to Catalyze Community Change\u00a0<\/span><\/h3>\r\nSuccess 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.<\/span>\r\n\r\n "},{"acf_fc_layout":"wysiwyg","_acfe_flexible_layout_title":null,"_acfe_flexible_toggle":null,"id":"background","wysiwyg":"

4. Growing and Scaling a Quality Network of Partners<\/span><\/h3>\r\nFor Inova, scaling the network meant focusing on <\/span>quality and accountability<\/b>, not just expanding participation. Through regular rejection audits and \u201cneeds action\u201d 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.<\/span>\r\n\r\nJust as importantly, Inova remains actively engaged in the broader nonprofit ecosystem. By participating in community conversations, aligning efforts with <\/span>Community Health Needs Assessment (CHNA)<\/span><\/a> priorities, and contributing to <\/span>communities of practice<\/span><\/a>, Inova ensures the network reflects real community context and shared goals.<\/span>\r\n\r\nThis combination of operational discipline and authentic partnership strengthens trust across the network and supports a coordinated, continuously improving system of care.<\/span>\r\n\r\n "},{"acf_fc_layout":"blockquote","_acfe_flexible_layout_title":null,"_acfe_flexible_toggle":null,"id":"","text":"\u201cIt has always been a challenge to ensure everyone serving community members, including healthcare, is aware of the amazing resources our community partners provide. By partnering with Unite Us and the Unite Virginia network, we not only elevate awareness among these organizations but also allow for seamless communication and navigation within our care network.\u201d <\/span>\r\n\r\n\u2013 <\/span>Leigh Guarinello, <\/span><\/b>Director of Community Health Programs, Inova Community Health"},{"acf_fc_layout":"wysiwyg","_acfe_flexible_layout_title":null,"_acfe_flexible_toggle":null,"id":"Impact","wysiwyg":"

<\/h2>\r\n

Impact<\/h2>\r\nThrough sustained community collaboration and a closed-loop referral system, Inova has driven measurable impact across patients, care teams, and partners.<\/span>\r\n\r\nKey Results<\/b>\r\n\r\nSince launching its system-wide SDOH strategy, Inova has screened <\/span>more than 1,000,000 patients<\/b> for SDOH needs.<\/span>\r\n\r\nRecent screening data revealed clear opportunities for intervention and whole-person support:<\/span>\r\n