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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.

ACL is proud to announce the final winners of the Social Care Referrals Challenge. Launched in March 2020, the competition sought 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. 

These partnerships are growing in both number and importance as demand for seamless integration of health care and social services continues to grow. However, lack of interoperability between the systems used by these organizations can lead to a lack of information sharing between partners, duplicative systems, and extra work for staff. Teams participating in this competition demonstrated how these barriers can be overcome through collaboration between health IT vendors, health care systems, and the aging and disability networks.

The three-phased challenge sought to catalyze development and optimization of interoperable and scalable technology solutions that leverage national standards for data exchange and common formats for resource directories. A bonus round was created to address taxonomy mapping, which emerged as an additional challenge early in the competition. 

Multi-stakeholder teams that included IT platform developers, leaders of state agencies and community-based organizations (CBO), health care providers, and payers competed for a total of $1 million in award prizes. Challenge teams successfully demonstrated approaches to closed loop referral exchange and technical adoption of open Application Programming Interfaces (APIs) for resource directories through the Open Referral initiative, specifically the use of Human Services Data Specifications (HSDS) and related mapping to Health Level Seven International (HL7®) Fast Health Interoperability Resources (FHIR®) profiles for standardized, open resource directories that allow for lookup and retrieval of resources by any state, CBO, or referral vendor. Challenge teams also have effectively tested the use of the Gravity Project’s coded terminologies to support the capture and exchange of social risk data across the health and human services ecosystem while promoting and preserving individuals’ privacy, safety, and security. In the bonus round, participating teams presented approaches to mapping taxonomies and terminologies across various social care domains to enable the use of standardized data and promote cross-sector care coordination. 

Grand Prize Winners:

  • The Missouri Aging Services Data Collaborative is a partnership between the University of Missouri – St. Louis (UMSL), Long-Term Care Innovation (LTCI), Cumulus, the Missouri Association of Area Agencies on Aging (MA4), and the Unity Foundation . The project successfully developed an interoperability hub to facilitate information sharing between organizations, systems, and platforms. The project also developed the Aging Services Dataset and Interoperability Standards (ASDIS), which categorize and organize hundreds of commonly used data elements and can be used to exchange data between partners and payers, regardless of which existing data system or vendor they use. The team enabled replicability and scalability of the project, including expanding technical components to include interoperability hubs for behavioral health services, disability services, veterans’ services, homelessness services, and more. Watch a video presentation on the project.
  • The FHIR-FLI team is led by MayJuun in collaboration with Open City Labs . FHIR-FLI is an open-source solution that helps connect the FHIR standard for health care interoperability to Google’s open-source Flutter framework which supports rapid development of applications. User responses are converted into a coded FHIR resource which can be accessed by a variety of systems. The team also worked with New Jersey 211 and Open City Labs (which has developed the Navigator 360 referral management tool) to more easily connect consumers to resources. This includes creation of a federated directory of community resources correlated from different sources and making it easier for providers to make or receive referrals across systems. Watch a demonstration.
  • The Thrive Hub team includes SC Thrive, Protech Solutions, and CareSouth Carolina . This partnership was established to create a web-based solution called ‘Thrive Hub’ that helps South Carolinians access various state and federal benefits applications. The ACL Social Care Referrals Challenge provided the opportunity to scale the solution so it can be used by medical care providers to send social care referrals to local providers and receive a response from those referrals, ultimately closing the loop on referrals and improving holistic care to clients. Additionally, Thrive Hub allows counselors to apply for benefits for the older adults and people with disabilities they are working with, conduct all their case management tasks, and search a database of statewide service providers for referrals and connections. The Hub also houses a Learning Management System that can be utilized by both clients and workplaces alike for personal and professional growth. Watch a video presentation. 

Bonus Phase Winners: 

  • The Missouri Aging Services Collaborative team is using machine learning technology to translate and match terms used in nationally-recognized social risk screening tools with terms used by service providers. A demonstration of the project included mapping Gravity Project Food Insecurity data elements with Nutritional Risk Screening data elements for Older Americans Act programs as a baseline for reporting. 
  • FHIR-FLI will scale their existing machine learning experience for mapping government benefit applications (e.g., SNAP), referral forms (e.g., WIC), and eligibility requirements collected from government websites and legal documents to map terms used for service referrals across a federated directory. The solution will align with nationally-recognized vocabulary and directory standards.

Learn More

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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 Problem

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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


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

Last modified on 10/27/2022

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