GridSocial, a closed-loop referral system designed for bridging gaps in care coordination between healthcare and social care organizations.
PALO ALTO, Calif., May 28, 2026 /PRNewswire-PRWeb/ -- SocialRoots.ai today announced the launch of GridSocial, a closed-loop referral system designed to help healthcare organizations, community-based organizations (CBOs), and social service providers stay connected throughout the referral journey while improving continuity of care and helping reduce avoidable medical costs over time.
While patients often leave hospitals with medications, discharge instructions, and follow-up appointments, successful recovery frequently depends on far more than clinical care alone. Transportation, meal support, medication access, home safety assistance, and community-based services all play an important role in helping patients recover safely at home.
In many cases, the referral itself is only the beginning. What happens afterward — ensuring services continue reaching the individual during recovery and follow-up care — can significantly influence long-term outcomes.
GridSocial was built to simplify referral management and strengthen collaboration across healthcare providers and community service organizations.
IMPROVING CARE COORDINATION ACROSS HEALTHCARE AND COMMUNITY SERVICES
In a typical care coordination scenario, Sophia, a 78-year-old patient recovering from a hip fracture, was preparing to leave the hospital following treatment. Her care plan included physical therapy, medications, and follow-up care, but because she lived alone, she also required additional support during recovery.
Before discharge, Sophia's care team initiated referrals directly through the Electronic Health Record (EHR), which then flowed into GridSocial to coordinate:
- Transportation assistance for medical appointments
- Meal delivery services
- Medication support
- Home safety assessments
- Visiting nurse follow-up care
As organizations accepted and responded to referrals, updates were automatically shared through the platform so healthcare providers, care coordinators, and community service organizations could remain aligned throughout the referral process.
If follow-up was needed, care coordinators received alerts and could quickly review service status, identify gaps in care, and respond before issues escalated.
In Sophia's case, maintaining visibility across transportation support, medication access, meal delivery, and follow-up care helped her recovery continue safely at home instead of resulting in a preventable hospital readmission weeks later.
SUPPORTING BETTER OUTCOMES WHILE REDUCING AVOIDABLE COSTS
Reducing healthcare costs often begins with identifying social needs earlier and maintaining visibility across follow-up care.
When organizations can respond faster and share information more efficiently, care teams spend less time repeating outreach efforts and more time addressing social determinants of health before smaller challenges become larger medical events. Over time, that connected support can improve patient outcomes, support value-based care initiatives, and reduce avoidable healthcare utilization across the system.
National healthcare initiatives have increasingly emphasized stronger coordination between clinical care and community services.
CMS's Accountable Health Communities Model focused on improving connections between healthcare providers and community-based services through screening, referral management, and community navigation programs designed to improve outcomes and reduce avoidable healthcare utilization.
SCREEN THE NEED. SEND THE REFERRAL. FOLLOW IT THROUGH.
GridSocial, the closed-loop referral system from SocialRoots.ai, is now available for a free proof of concept.
ABOUT SOCIALROOTS.AI
SocialRoots.ai is a Palo Alto-based technology company building care coordination and referral management solutions for healthcare and social care organizations across the United States. Its platforms are built for the operational realities of health systems, FQHCs, community-based organizations, and federally funded social service programs.
Learn more at https://socialroots.ai
Media Contact
Bala Murali, SocialRoots.ai, 1 8472547133, [email protected], https://www.socialroots.ai/
Monisa Selvakumar, SocialRoots.ai, 91 9600863293, [email protected], https://www.socialroots.ai/
SOURCE SocialRoots.ai
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