ACL Announces Social Care Referrals Challenge Phase 1 Awardees

The Administration for Community Living (ACL) announces Phase 1 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.

The comprehensive proposals demonstrated multi-stakeholder approaches to addressing social determinants of health (SDOH) through alignment of health care and community-based services. ACL’s Social Care Referrals Challenge aims to bridge the gap between health and social care by enhancing scalable approaches for sharing standardized data on social determinants and person-centered plans through the use of open resource directories that seamlessly connect and interoperate across community-based organizations (such as area agencies on aging and centers for independent living) and health care systems.

Forty proposals were scored individually by multiple judges and evaluated by an expert panel. Of these, 12 were selected to advance to the second phase of the competition. Some teams with similar geographies and supporting similar communities developed plans to merge efforts for Phase 2, leading to greater opportunities for streamlining their work to support statewide approaches. Each will be awarded $30,000 to support continued development of their solutions as they compete for a second award of $60,000 and a grand prize of up to $140,000.

The challenge competition is part of a national effort to align health care and social service delivery in order to maximize health and quality of life outcomes. Services delivered in the home and in the community that prevent falls, address food insecurity and transportation issues, manage chronic disease, support employment and economic independence, reduce social isolation, and address other non-medical risk factors have been shown to improve health outcomes and reduce the cost of care. These teams have recognized the need for managing referrals for these types of social services, avoiding duplicative workflows in an already strained system, and prioritizing opportunities to provide better support and care for the people served by the health care system and social service system, particularly for the most vulnerable populations.

The Phase 1 winning solutions and finalists are as follows*:



This team is building a multi-lingual, cross-platform application that facilitates social referrals through rapid user entry of social determinants of health data, using the Fast Healthcare Interoperability Resources (FHIR) standard for data storage and exchange. FHIR-FLI is targeting the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) survey as the prototypical questionnaire, as it is scientifically-derived, well-validated, has 26 language translations, and exists in a LOINC FHIR API standard. Clients will be referred to community resources based on their identified needs, and local agencies will be able to track referrals and get insight into needs at the community or individual level. By embracing open-source app development with Google’s cross-platform UI toolkit, Flutter, and developing educational training videos on Flutter’s modular components, it is intended to extend well beyond PRAPARE. This prototype can serve as the technical standard for FHIR applications using a single code base that spans all app platforms. This isn’t just creating one survey, rather giving everyone the tools to make their own, interoperably.


AMA Health Information Solutions

FIRE Wire is a lightweight, standards-based messaging and directory solution designed to facilitate point-to-point communication between individuals across organizations. With FIRE Wire, physicians and others will be able to easily establish trust and exchange messages. FIRE Wire will enable trusted communication and become a lightweight facilitator of directory access, messaging and referrals. FIRE Wire will use a simple trust framework modeled after agreements currently used in telemedicine and related solutions. FIRE Wire will include a standards-based directory service leveraging the American Medical Association's Physician Masterfile, a comprehensive database of U.S. physicians. The solution will integrate with the Aunt Bertha social care network and other directories in the future i.e., payers. A secure inbox with email or chat-like messaging capability will support end-user applications, with EHR integration planned and standalone access made available via web and mobile applications. Through these applications FIRE Wire will provide a user-centric experience with search, contact request, trust establishment, and secure messaging.

Service Net

Beneficent Technology, Inc., DBA Benetech

The Service Net platform is designed to solve the fragmented, redundant resource directory data silo problem. Leveraging Open Referral’s Human Services Data Specifications, Service Net enables organizations to collaborate in the maintenance of resource directory data that they previously managed in competitive isolation. By enabling pre-competitive cooperation around this critical public information, Service Net can empower the health and social ecosystem to make the safety net more visible: more accessible for people in need across any context, as well as more analyzable for researchers, decision-makers, and policy-makers working to improve resource allocation for communities’ well-being. Service Net can receive resource directory data from multiple sources, connect matching records to each other, guide stakeholders through the process of verifying information, and share the resulting information back with contributors and the broader ecosystem as standardized open data. As this scalable infrastructure is adopted by governments, funders, referral providers, CBOs, and health stakeholders, Service Net will transform the sector through interoperability, enabling each player in the ecosystem to focus on what they do best, with the best data at their fingertips, fostering collective impact at scale. With support from the ACL challenge, Service Net plans to enhance the platform’s capabilities for conflict resolution, vocabulary alignment, and API-driven system integrations, alongside other key features.

South Carolina Referral System

SC Thrive

SC Thrive is a 400+ partner-collaborative that's been serving vulnerable South Carolinians for more than 10 years. Thrive Hub is a platform for integrated, community case management. Thrive Hub's key benefits include closed loop features that tracks if a seeker got services; holistically measures how that service helped them and integrates open APIs with any organization. Thrive Hub also offers a toolkit with built-ins like integrated eligibility, waiting-list workflows, secure videochat, ad-hoc reports, and more. Thrive Hub is participatory, not paternalistic. In less than two years, Thrive Hub has been deployed 200+ partners statewide and integrated with SC DSS and SC DHHS for benefits applications. Expanding Thrive Hub’s utilization statewide has created a singular, comprehensive system for South Carolinians seeking services, and has provided valuable data guiding informed decisions. Thrive Hub is ready to scale and the existing, strong partnerships with the Medical University of South Carolina, Trident United Way, and Tri-County Cradle to Career Collaborative opportunely position the team to use this challenge to weave Gravity Project Standards into an already robust backbone of collaboration.

United Way for Southeastern Michigan

United Way for Southeastern Michigan

To tackle challenges of resource navigation and increase opportunities for data-driven community health planning, United Way for Southeastern Michigan is working with partners to develop a Community Information Exchange (CIE). The Southeast Michigan CIE is a person-centered hub for identifying health and social service needs and a network of service providers and partners aligned to ensure those needs are met and documented. As part of the CIE, United Way is partnering with Henry Ford Health System, community leaders, and local agencies that lead aging networks through a demonstration project to pilot a closed-loop referral system to coordinate health and social needs and explore the development of standardized social needs screening and assessment tools. This project will utilize a person-centered approach and will resource our commitment to ensure seniors can use their knowledge and lived experiences to build a better care system for themselves and their counterparts. This project will capitalize on the growing interest among community stakeholders to align screening and assessment tools, track services provided to individuals, and increase cross-sector communication. It is expected this project will improve the experience of individuals navigating the system of health and human services, enable effective risk stratification and predictive modeling for health system partners, and improve data sharing capabilities for social service providers.

United Way of Salt Lake

United Way of Salt Lake

United Way of Salt Lake, in collaboration with Leavitt Partners, is bringing together state government offices, including Medicaid, Department of Human Services, the Governor’s Office of Management and Budget, Health Information Exchanges, healthcare providers, Medicaid plans, community-based organizations, along with the talent and expertise in information and referral services of Utah 211 to create a two-part solution to address social determinants of health. This team of dedicated stakeholders are working together to navigate current siloed operations to envision a future where screenings, referrals via closed-loop systems, follow-up, and tracking of progress over time is the new operating structure for providers. This shifts the user control to the client, having full access to their records and the consenting ability for their information. This two-part solution includes both the use of a statewide closed loop referral platform through a multi-state partnership, and a client-centric mobile application that allows access to an individual’s data and their ability to share that information with organizations they choose. It creates an ecosystem in which APIs open up any existing platforms or programs being used by agencies to communicate with each other through interoperability and shared data standards. We believe this will not only be a solution for the partners being convened in Utah but could be scaled to other states or even nationwide.

Missouri Aging Services Data Collaborative 

The following three teams below have agreed to partner and merge as one team for Phase 2 of the competition. This new team brings a collective vision for stronger aging services data connectivity across the State of Missouri through data mapping, resource data alignment, and referral platform integration.

Data Standards for MO AAAs

University of Missouri - St. Louis

This project aims to establish data and interoperability standards for aging services client data within the context of community-based aging services — connecting to the Gravity Project (which aims to standardize medical codes and exchange standards to facilitate the use of SDoH-related data across a wide range of care management settings between health care and human services providers, and others as authorized and appropriate) as a bridge from social services to healthcare, not the other way around. It is anchored in data collected and managed by Area Agencies on Aging (AAAs) across Missouri that provide a substantial range of long-term services and supports (LTSS) for older adults. While informed by resource data exchange efforts like Open Referral, this project will focus on client data exchange, or the responsible flow of information about clients as shared among various kinds of service providers for care coordination. By aligning these efforts with the Gravity Project, this project has the potential to have an even greater impact as a template for how to standardize social service data within the context of social services themselves — facilitating interoperability among SDOH platforms, HIEs, EHRs, and social service providers nationwide.

MOKAN Bi-State Networks

Guardian Group, LLC

The MOKAN Nested Networks concept supports interoperability and cooperation between and among the health care and social service sectors, especially those supporting high-cost and high need populations (such as aging and disability networks) relating to SDOH. The design enables the authorized sharing of: social needs assessment results; joint, coordinated case plans; multi-and-cross-domain closed-loop referral information; and performance, utilization, outcome, and financial measurement, advanced analytics, predictive modeling, and reporting. By assisting and enabling each other, collective technical knowledge and expertise will be leveraged in a continuous learning environment to the health and wellbeing benefit of clients/patients/caregivers, communities/providers, and the region/health systems/payers/state agencies. Long-standing and newly-formed professional relationships, social networks, and workflows will be represented in the interconnected architecture. Special emphasis in the planning and implementation will be given to the ecosystem supporting older adults and people with disabilities and the related interoperability issues in Missouri and Kansas.

St. Louis Regional Coalition

Aging Ahead

The scalable Cumulus platform allows aging & disability organizations, such as Area Agencies on Aging and other community-based organizations to rapidly assemble partners to collaborate on current and emerging projects. Cumulus, a replicable web-based collaboration, interoperability, and analytics platform allowing organizations to swiftly mobilize partners across disparate data systems. Scalable for collaborations of any size and built on an integration layer that supports modern formats, including HL7 FHIR standards, Cumulus helps organizations bolster partnerships, securely share data and streamline referral processes. With powerful analytics, Cumulus provides users with important metrics across their entire data set. Cumulus utilizes modern standardized data formats (HL7 FHIR), including APIs, but also easily integrates with the legacy systems that may lack modern integration approaches through the Cumulus data translation service – converting data from systems using their native formats, decreasing both implementation costs and timelines.

New York SDOH Referral Collaborative

The three teams below have agreed to partner and merge as one team for Phase 2 of the competition. This team will focus on statewide consensus building and standards based on specific use cases and workflows with a technical framework that is interoperable, responsive, and scalable.

Healthy Together

Alliance for Better Health

In partnership with the regional Health Information Exchange, we will implement a regional referral hub using OpenReferral as the industry standard. This will enable medical, social, and behavioral health providers to interact with the regional referral directory and initiate referrals to any participating organization. The foundation of the directory will be our current Healthy Together system, which incorporates hundreds of providers in eight counties in New York State. Healthy Together will incorporate standards for the “payload” of every referral where possible, using standards as they evolve in close concert with The Gravity Project. A special focus will be on the FoodRx model which enables any medical or behavioral health provider to send a FoodRx “prescription” for any individual to the food pantry network using certified Health Information Technology. These initiatives will continue our five-years of work that have demonstrated the effectiveness of SDoH interventions to improve people’s health while reducing total cost of care, and finally creating a technical bridge between the previously siloed social, behavioral health, and medical providers.

Northwell Health

Northwell Health

Northwell Health will leverage CBO partnerships to create regional Community Partner Networks (CPNs) in geographic areas where our patients require the most assistance. Overall, the proposed solution will allow for multi-disciplinary teams across organizations to work together, assuring continuity of care as well as accountability in creating, sharing, and maintaining more complete patient-centric records that include social and clinical data needed to support care decisions. The technology components of the solution will integrate a closed-loop referral platform (NowPow) that is shared with CBOs, with our own interoperable and robust healthcare IT infrastructure. Northwell will create bi-directional interfaces between the shared eReferral platform and Northwell Health’s EHR, Care Management system, and private HIE. The proposed solution design aligns with New York State’s use of common standards and leverages HL7 FHIR to continuously improve interoperability. The solution will aggregate referral data from multiple care settings and eliminate duplicative workflows by streamlining the referral process for Northwell Health’s care teams to create referrals, CBOs to receive the referrals, and for the referral results to be shared back with Northwell Health.

SHIN-NY 2-1-1 New York

New York eHealth Collaborative

The New York eHealth Collaborative (NYeC), and 2-1-1 New York, Inc. (2-1-1) have partnered to create the framework and statewide governance structure for collaboration and information change across established and robust networks, the Statewide Health Information Network for New York (SHIN-NY) and 2-1-1. The governance will collaborate on a comprehensive statewide community-based resource directory. This will enhance two robust statewide information exchange networks in supporting referrals, including the sharing of critical social determinants of health. Through a robust standards-based development process and with a focus on workflow, the SHIN-NY and 2-1-1 will build a first of its kind collaboration to assist all New Yorkers in attaining life-saving and enriching services. In close collaboration with stakeholders, NYeC will provide expertise in governance, policy, and data analysis to design and implement. As each network evolves to different use cases and data types, our partnership will explore ways that the SHIN-NY can support 2-1-1 with increased referrals and potentially directory attributes such as secure message addresses, real time updates, availability of services, and cultural competency.


Honorable Mentions

The following teams received special recognition for being top contenders in the competition. Critical partnerships were forged by these teams and are recognized as successful interventions for this work.

Partners 4 Community Health

Holon Solutions

Community4Health – a cooperative effort between Holon Solutions, Answer Health, G-Health Enterprises, MiHIN, NextGen, and Referral Point – improves care using a unique bi-directional delivery technology that puts the right information in front of the right people, at the right time. Powered by CollaborNet, it puts the insights providers need to deliver the most informed quality care in their hands how and when they need it, while connecting providers from across the community to facilitate care coordination and collaboration during patient handoff and transition among healthcare and social service locations.

Activate Care

Activate Care

Activate Care is a leading digital health company in the field of community-based care coordination, focused on addressing social determinants of health. The SaaS platform, Activate CareHub, helps local leaders, healthcare providers, managed care organizations, government agencies, and social services engage in needs assessment and screening, risk identification, individualized care/service planning, community resource navigation, and closed-loop referral management with partners and stakeholders across the continuum of services and supports.

At Your Service


At Your Service (AYS) is an advanced system to streamline and standardize the identification, creation, maintenance and sharing of entries in community service directories or catalogs. It includes 1) a data entry workbench that guides users to correctly and consistently create entries in the Human Services Data Standard (HSDS), AIRS taxonomy  and/or custom data formats, 2) a manager of the workflow for checking and approving draft entries and 3) a maintenance platform that uses automation to check the validity of entries and facilitate editing.

WeWaLife LLC

Builds operates, and maintains an open-architecture, national community health information ecosystem consisting of the following two main components: Leveraging a comprehensive range of clinical, behavioral, social risk, and social determinants of health factors, and developing a decision-support and care-referral system capable of identifying patients in need of various wraparound social services. This also includes screening integrated with the search function so that suggested resource lists are automatically generated once screening is completed with a Referral 360 Technology platform to send referrals to community resources and track referral outcomes.


Harvard Pilgrim Healthcare

CareRS collaborates with healthcare and technology professionals focused on expanding access to social services through focused innovation in SDOH needs qualification and referral management. CareRS leverages cloud technologies, including conversational AI (DIYVA) and NLP, to screen and quantify all patients’ social needs. SDOH data will be normalized and stored in a secure SDOH FHIR data store. The conversational AI is also an additional channel for patients to give consents and receive referral approvals. CareRS dashboards measure outcomes meaningful to all stakeholders, namely reducing care gaps and unnecessary healthcare expenditures. These measures will quantify the value of CareRS and establish executive buy-in for sustained investment.

ACL thanks the expert panel of 19 judges that participated in the review process and provided valuable insight to inform our final decision of winners! More information about the Social Care Referrals Challenge, including deadlines and evaluation criteria, can be found at   


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

Last modified on 11/02/2021

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