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ACL Announces Social Care Referrals Challenge Phase 2 Awardees

December 20, 2021

ACL is announcing the Phase 2 winners of the Social Care Referrals Challenge competition. Launched in March of 2020, the challenge will award prizes for developing and optimizing interoperable and scalable technology solutions that foster connections between community-based organizations and health care systems in support of holistic health and social care for older adults and people with disabilities.

Phase 1 teams  presented design and concept proposals for technology solutions that facilitate social referrals through closed loop functionalities and that enable more efficient data sharing across health and human services organizations. These solutions addressed approaches to presenting data on the individual, organizational, and regional levels about referrals, the prevalence of social determinants of health (SDOH), and service utilization and outcomes to guarantee opportunities to strengthen coordination across communities, states, and the health care system. Teams also presented commitments to adopting standards for open resource directories and technical standards for SDOH data. 

In Phase 2, teams demonstrated the use of standards for referral data collection and exchange through enhanced use cases for technical functionalities. Teams also identified a collaborative governance model with confirmed collaborators, defined roles and responsibilities, data agreements, and end user workflows. Through expert panel and judging reviews, ACL awards four teams $60,000 each to move forward to the final implementation phase of the competition. 

Phase 2 winning solutions and finalists are as follows*:

  • Closing the Loop Together in Southeast Michigan: This team is led by the United Way for Southeastern Michigan and includes a collaboration with the Senior Regional Collaborative, the Detroit Area Agency on Aging, and a community food pantry. The collaboration is to develop a Southeast Michigan Community Information Exchange data hub that will adopt a model for bi-directional information exchange within a software-agnostic hub. An additional use case includes exchange of social referral data for enrollment into state benefits. 
  • FHIR-FLI: This team is led by MayJuun LLC and includes a strategic partnership with Open City Labs, Inc. This solution is built on a cross-platform mobile app that uses Fast Healthcare Interoperability Resources standard to assist with social care referrals. The team created a Needs Assessment Tool App for the New Jersey Integrated Care for Kids program and included a Federated Directory that will enable closed loop referrals with a management tool. 
  • Missouri Aging Services Data Connectivity & Interoperability: This team is a collaboration between three Phase 1 awardees led by Long Term Care Innovation, the University of Missouri - St. Louis, and the Guardian Group. This collaborative focused on 1) elevating the role that Area Agencies on Aging (or AAAs) and other community-based organizations play in statewide data and interoperability efforts; 2) connecting multiple organizations, platforms, and data sources to each other; 3) advancing interoperability and standards-first data sharing within social services; 4) and enabling the replicability and scalability of these concepts to other states and populations.
  • Thrive Hub South Carolina Referral System: This team is led by SC Thrive and Protech Solutions. Their solution included a focus on direct secure messages for outbound referrals with an approach that allows providers and stakeholders to continue using their existing systems while building seamless integrations between EHRs and Thrive Hub to easily exchange information about patients and their social care referrals and outcomes. The demonstrated use case is focused on social care referrals from the Thrive Hub system to food services providers. 

ACL thanks the panel of 7 judges that participated in the review process and informed the final decision of Phase 2 winners!

The next phases of this Challenge competition will include Phase 3 and a Bonus Phase. Phase 3 will focus on implementation and testing of Gravity Project standards based on proposed integrations and unique use cases presented by the four Phase 2 awardees. The Bonus Phase of the competition will address two key goals: directory federation and mapping taxonomies with submissions focusing on design/concept and strategy for national scale solutions.  Find more information about the Social Care Referrals Challenge.

* Project descriptions were extracted from materials submitted for the competition; ACL does not endorse the organizations or solutions.

Last modified on 12/20/2021

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