Challenge: Innovative Technology Solutions for Social Care Referrals

ACL’s Social Care Referrals Challenge seeks health IT solutions to support health care systems and community-based organizations in partnering to provide holistic health and social care for older adults and people with disabilities.

The Problem

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

Since 1965, the aging and disability network has been a trusted resource for meeting these needs, delivering home- and community-based services to one in five of America’s older adults, as well as people of all ages with disabilities. This network includes more than twenty thousand community-based organizations and is present across the U.S. These organizations have unmatched expertise in local culture and needs, service coordination and delivery, and securing benefits, services and supports that maximize independence and functioning. Their reach into homes also provides an opportunity to identify risks and connect people to interventions before health issues become crises. Consequently, partnerships with this network have proven to be an effective way for health care organizations to include interventions to address social determinants in the continuum of care.

These partnerships are growing in both number and importance as demand for seamless integration of health care and social services continues to grow. As a result, the need for interoperable IT infrastructure to connect the partners has become critical. 

The health care and social services sectors have invested in technology independently. For example:

  • States have invested in resource directory and referral management systems to support their efforts to streamline and improve their systems for connecting older adults and people with disabilities to long-term services and supports.

  • Provider- and plan-specific referral platforms are often not leveraging the existing network that enables access to a variety of services and supports that address social needs.
  • In addition, health IT developers are implementing innovative platforms that refer people to community resources, but they often create wall gardens in communities because they do not incorporate common standards and lack interoperability.

This siloed development is:

  • Creating inefficiency in managing referrals for social services;
  • Creating duplicative workflows in an already strained system; and
  • Impeding opportunities to provide better support and care for the people served by either system.

The Challenge

The Administration for Community Living (ACL) at the U.S. Department of Health and Human Services (HHS) announced a competition for state and community leaders in the aging and disability network, health care systems, health plans, and health IT vendors to cultivate care coordination by developing and/or optimizing interoperable and scalable technology solutions. Participants were invited to work collaboratively on enhancing scalable approaches to secure sharing of standardized data on social determinants and person-centered plans through the use of open resource directories that seamlessly connect and interoperate with health care system electronic health records to community-based organizations. This Challenge includes developing prototypes and implementing technical solutions that track referral patterns and gaps in service that visibly display social service and health-related outcomes over time.

The Challenge will compete in three phases, with cash prizes awarded in each phase. The total prize pool available is $500,000.  

Note: This Challenge closed for applications on January 6, 2021.

March 26, 2021: ACL Announces Social Care Referrals Challenge Phase 1 Awardees

ACL Announces Social Care Referrals Challenge Phase 1 Awardees

Outreach Toolkit

Can you help spread the word about the Challenge? Use materials (sample email, social media posts, and graphics) from this outreach toolkit. Thanks!


Updated November 10: ACL Social Care Referrals Challenge Competition FAQ

October 15 Webinar: Challenge Updates and New Resources

Collaborate with teams and interested solvers here:

July 28 Webinar: Introduction to Social Care Referrals Challenge

New Bonus Phase

ACL is excited to announce a new Bonus Phase for the Social Care Referrals Challenge. The Bonus Phase will address two key goals: Directory Federation and Mapping Taxonomies. All Phase 2 teams are eligible to compete and submit a design/concept and strategy for national scale solutions.

Goal 1 – Directory Federation:

  • Addresses open source components to enable transformation, matching, collaborative editing and syncing of service directory information across multiple technology systems, (e.g., resource directories, community referral platforms, EHR platforms). Exchange incorporates the ability to identify, differentiate, branch, patch, pull, and push directory resource data.
  • The goal is to reduce the need for redundant, out-of-date, siloed, or aggregated resource directories with a federated model that identifies validated resources and returns standardized resource data that supports health and social organizations to better addresses individual needs.

Goal 2 – Mapping Taxonomies:

  • Representing taxonomies and other controlled terminologies in use across sectors, through tools that facilitate mapping and cross-walking of taxonomies that describe types of people, situations, services, etc. These tools should enable web services to cross-reference known taxonomy terms via uniform resource identifiers (URIs) and across community referral platforms with existing information and referral systems that CBOs routinely use.
  • The goal is to map different terminology codes to standardized codes (e.g., homegrown codes to standardized codes, medical terminology to social codes, etc.) for specific social domains and risk factors enabling standardized data within referral management. Other uses for terminology mapping is to enable standardized data for use in eligibility, billing, measurement, and population health analytics. This terminology mapping will support the taxonomy of health and social services and create a common language.

Teams may propose solutions for one or both of the goals. Up to two prize winners will be awarded $100,000 each. The Bonus Phase submission period will run through December 3, 2021.


If you have questions or want to learn more, please email

Last modified on 09/13/2021

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