This use case follows Norma Garcia, a patient managing diabetes, as her care team works to connect her with the food and nutrition support she needs. It shows how the referral moves across the practice, health plan, and community service provider, from identifying the need through authorization, service delivery, and follow-up. The story highlights where delays, unclear responsibilities, and limited information sharing can interrupt care, and how a more coordinated process can help patients receive support sooner. Organizations can use the use case to strengthen referrals, data sharing, and follow-up across healthcare and community partners.