Social, economic, and environmental conditions are known to impact up to 50 % of an individual's health. The process of identifying needs and referring individuals to resources is social prescribing. While technologies have been developed, a major barrier is that the social prescription process is poorly understood. Few healthcare systems have tools or workflows that systematically collect individual needs and provide reliable referrals to Community-Based Organizations (CBOs). The purpose of this research is to understand the existing process of a healthcare system and implement a digital health tool to assess its alignment with the healthcare system. We conducted 21 semi-structured interviews with clinical teams (i.e., doctors, nurses, social workers, and administrators) to understand the barriers and facilitators for Health Information Technology (HIT) and social care referrals. We also piloted a HIT, Smart Community Health, with 21 recruited participants from the healthcare system. Our results show that barriers exist at the individual level, healthcare system level, and across CBOs. Healthcare team members used interpersonal communication, championing, and person-centered care to facilitate social care referrals to CBOs. Lastly, the role of HIT remains ambiguous; participants stated that there would be both positive and negative aspects of integrating technology within this process. When we piloted the HIT with 21 participants, we found that 61 % of patients were able to connect with CBOs, but only 26 % were able to get resources. This indicates that there are still significant challenges to getting resources to individuals with needs.