The Primary Care Coalition (PCC), Nexus Montgomery hospitals, and community-based food assistance providers launched the Social Health Alliance (SHA) in February 2025 to strengthen connections between hospitalized patients and food support services after discharge. Supported by Maryland Physicians Care, this two-year initiative is designing and piloting a more coordinated referral model. It should also generate critical insights at the systems level-- increasing visibility into community capacity and identifying patterns in unmet need.
The Alliance is initially focused on food insecurity, creating a stronger link between hospital care and community-based support. It is designed to help hospitals make more targeted referrals, provide food assistance organizations with better insight into demand, and support a more coordinated response to patient needs.
After 18 months of strategy development and planning, PCC is putting the initiative into action through three interconnected components: focus areas, patient journey stages, and workgroups. The focus areas center the initiative’s program goals—aligning supply and demand, improving coordination, and enabling case management—while also addressing community-based organization processes on the supply side, hospital workflows related to demand and referrals, and upstream screening.
These efforts are organized across three key stages of the patient journey:
Supporting implementation are three workgroups that serve as the Alliance’s execution engine: Community Resources, which focuses on service readiness and response; Health Systems, which addresses demand generation and referral quality; and Cross-Sector Collaboration, which promotes system alignment and shared best practices. Together, these workgroups move through each stage in a common cycle, helping align supply and demand across the full patient journey.
The Alliance is initially focused on food insecurity, creating a stronger link between hospital care and community-based support. It is designed to help hospitals make more targeted referrals, provide food assistance organizations with better insight into demand, and support a more coordinated response to patient needs.
After 18 months of strategy development and planning, PCC is putting the initiative into action through three interconnected components: focus areas, patient journey stages, and workgroups. The focus areas center the initiative’s program goals—aligning supply and demand, improving coordination, and enabling case management—while also addressing community-based organization processes on the supply side, hospital workflows related to demand and referrals, and upstream screening.
These efforts are organized across three key stages of the patient journey:
- Front Door focuses on visibility and access, ensuring needs are accurately identified and matched to visible, appropriate services;
- Handshake centers on referral workflows to produce referral communications that are complete, actionable, and consistently processed; and
- Closing the Loop emphasizes demonstrating successful patient connection to providers and receipt of services.
Supporting implementation are three workgroups that serve as the Alliance’s execution engine: Community Resources, which focuses on service readiness and response; Health Systems, which addresses demand generation and referral quality; and Cross-Sector Collaboration, which promotes system alignment and shared best practices. Together, these workgroups move through each stage in a common cycle, helping align supply and demand across the full patient journey.
The initiative’s data framework also has three parts: operations, measurement, and analysis:
- The operations component uses the Findhelp platform to route and reroute referrals across member organizations, provide capacity visibility through manually updated program cards, and track referral acceptance status to support day-to-day case management.
- The measurement component collects monthly data on hospital screening and referral demand as well as community-based organization referral results (received, accepted, declined, and completed), using standardized definitions that allow for comparable, aggregated reporting.
- The analysis component examines trends in demand, completion, drop-off rates, and unmet need; identifies pressure points where demand exceeds available services; and generates evidence to support resource planning, advocacy, and future funding.
The Alliance reflects PCC’s core strength: connecting partners across sectors to create practical pathways for change. “One area where we’ve already seen measurable progress across the alliance is hospital screening rates,” says PCC Director of Community Resilience Rachel Lee.
Across partnering Nexus Montgomery hospitals, screening rates have increased from 73% to 85%. “This matters because stronger screening helps identify social needs earlier, creates more opportunities for intervention and referral, and gives us a much clearer understanding of the factors contributing to utilization and readmissions across the system.”
The Alliance creates new opportunities for collaboration between healthcare and social service providers at a critical stage: when patients require hospital care. These moments can provide valuable insight into broader community needs while offering a practical entry point for stronger coordination and case management.
“Collaboration needs to happen across the entire continuum of care, but hospitals are often where the connection between health and social needs becomes most visible,” said Rachel Lee, Director of Community Resilience at PCC. “That gives us an opportunity not only to connect patients to support, but also to better understand where the system is working well and where there are opportunities to improve coordination across the community.” The goal is to use that information to drive action and continuous improvement, so partners are not just responding to challenges as they arise, but strengthening the system over time.
Ultimately, the Alliance is working to create a more connected system of care across the county: one that better supports patients not just inside the hospital, but across the full system of care.
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