ACL Challenge Competition: 

Innovative Technology Solutions 

for Social Care Referrals

July 28, 2020
Agenda

Ø Welcome and Introductions 

Ø Background 

Ø Overview of the Challenge 

Ø The Gravity Project 

Ø Phase 1 Submission Details 

Ø Resources 

Ø Q&A
Welcome and 

Introductions
What is a Challenge?

Unique opportunities with Prize Challenge 

Competitions: 

– attract new and unlikely innovators to the table 

– have merits over grants/contracts 

– speed and ease of use 

– rewards outcomes not process 

– g enerate interest in new services, data or 

technologies 

– excuses us from the comforts of bureaucratic 

routine, force us to reframe long - standing 

problems, and animate our creativity
Social Care Referrals Challenge: 

The Problem
Why Now?

• Partnerships between health care and community - based 

social services organizations have been shown to 

improve health outcomes and lower costs. 

• Increased collaboration with the existing networks of 

community based organizations that serve older adults 

and individuals with disabilities have proven to be an 

effective way for health care organizations to include 

interventions that address social determinants of health in 

the continuum of care. 

• A growing class of technology vendors supporting closed 

loop referrals between health care and social services are 

gaining market share quickly.

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Today’s Landscape of Health and 

Social Care Coordination

• States have invested in resource directory and referral 

management systems to support their efforts to streamline and 

improve access to LTSS for older adults and people with 

disabilities. 

• Individual health plans and health systems are implementing 

technology approaches to screen and refer individuals to 

community resources in order to address their social needs and 

improve their health and overall well - being. 

• H ealth IT developers are implementing innovative platforms that 

many hospitals or health care plans are using and there is desire 

to refer people to community resources, but there is a lack of 

common standards and lack interoperability with existing systems.

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The Need to Address Interoperability

• Individuals seek care from providers with differing platforms that lack 

seamless connections with community based organizations. 

• Existing technology solutions lack interoperability and scalability 

within and across communities. 

• Provider and plan specific referral platforms are often not leveraging 

this existing infrastructure that enables access to a variety of services 

and supports that address social needs. 

• Duplicative spending across stakeholders as they independently 

contract for different referral vendors to secure community 

connections. 

• CBOs are faced with the burden of accessing multiple platforms to 

receive and act on referrals. 

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The Challenge
Establish A Shared Technology 

Infrastructure 

ACL is seeking interoperable technology solutions 

developed by multi - stakeholder teams that: 

• More efficiently share data to enable standardized 

referral processes and better informed decision - making. 

• Incorporate closed - loop referral protocols to track and 

support individuals when they obtain services from any 

organization or health care provider within the network. 

• Produce data on the individual, organizational, and 

regional levels about referrals, the prevalence of social 

determinants of health, and service utilization and 

outcomes.

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Forming a Team

• Critical partners for designing solutions to this Challenge 

should include a team of key stakeholders. 

• Teams should include h ealth IT developers, health care 

providers, health plans, state and local agencies that lead 

the aging and disability networks and Medicaid, and 

others with relevant technical expertise in data standards, 

architecture, and/or data analysis.

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Challenge Details

The total prize award available is $500,000. 

ØPhase 1: Concept & Design Submission (July 2020 – 

December 2020) 

– Up to six prize winners at $30,000 each 

ØPhase 2: Proof of Concept & Demonstration (January 

2021 – June 2021) 

– Up to three prize winners at $60,000 each 

ØPhase 3: Implementation & Testing - (July – December 

2021) 

– One final prize winner at $140,000 or more

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The Gravity Project
The Gravity Project: 

Consensus - driven Standards on 

Social Determinants of Health 

ACL Challenge Competition Webinar, July 28, 2020 

Evelyn Gallego , MBA, MPH, CPHIMS 

Gravity Program Manager, EMI Advisors LLC
Agenda

§ Business Drivers 

§ Project Scope 

§ Project Approach & Accomplishments 

§ Use Cases & Terminology Framework 

§ eReferrals in FHIR IG Build 

§ How to Engage
Business Drivers

There is broad 

consensus that SDOH 

information improves 

whole person care and 

lowers cost. Unmet social 

needs negatively impact 

health outcomes. 

• Food insecurity correlates to 

higher levels of diabetes, 

hypertension, and heart failure. 

• Housing instability factors into 

lower treatment adherence. 

• Transportation barriers result 

in missed appointments, 

delayed care, and lower 

medication compliance.

One of the biggest barriers to 

addressing social risk and social 

needs in clinical settings is the limited 

standards available to represent the 

data. We need standards to promote 

the: 

• Collection and use of the data; 

• Facilitate the sharing of the data across 

clinical and non - clinical organizations; 

and 

• Facilitate payment for social risk data 

collection and intervention activities 

Key Learning: Despite increased interest 

around identifying and addressing SDOH 

in context of US health care settings, 

existing medical coding vocabularies and 

health information exchange standards are 

poorly equipped to capture related 

activities.

Arons A, DeSilvey S, Fichtenberg C, Gottlieb L. Documenting social determinants of health-related clinical activities using standardized medical 

vocabularies. JAMIA Open. 2018;2(1):81-88. (http://sirenetwork.ucsf.edu/tools-resources/mmi/compendium-medical-terminology-codes-socialrisk-factors ) 
Enter the Gravity Project...

Goal 

Develop consensus - driven data standards to support use and 

exchange of social determinants of health (SDOH) data within 

the health care sectors and between the health care sector and 

other sectors.
Gravity Overview: Two Streams

Technical 

(FHIR)

SDOH 

Domains 

(Terminology)

CODED 

VALUE SETS

FHIR IG Ballot & 

Publication

Publication in NLM 

VSAC & ONC ISA

Community & FHIR 

Coordination 

Community Data 

Set Identification 

New Code 

Submissions Coding Gap Analysis & 

Recommendations 

FHIR IG 

Testing

FHIR IG 

Development

4

1

2

3

4

1

2

3
Accelerating Adoption Using Nationally 

Recognized Standards

Fast Health Interoperability Resource Clinical Document Architecture (CDA)
Gravity Community

1,100+ Participants 

https://confluence.hl7.org/pages

/viewpage.action?pageId=46892

669#JointheGravityProjectGravityProjectMembershipList

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Gravity Project Accomplishments to Date

§ Developed consensus - approved Use Case Package: 

https://confluence.hl7.org/display/GRAV/Gravity+Use+Case+Package

§ Developed consensus - approved Food Insecurity Data Set: 

https://confluence.hl7.org/display/GRAV/Food+Insecurity+Domain

§ Developed Food Insecurity Gap Analysis & Coding Recommendations Report.

§ Submitted new code applications for Food Insecurity concepts to Regenstrief, 

ICD - 10, and SNOMED CT. 

§ Developed Gravity Manuscript Outline (ONC Deliverable)

§ Developed draft SDOH FHIR Implementation Guide (IG): 

https://confluence.hl7.org/display/GRAV/Gravity+SDOH+FHIR+IG

§ Completed two SDOH IG Connectathons : 

https://confluence.hl7.org/display/GRAV/Gravity+SDOH+FHIR+Connectathons

§ Developed draft Housing Instability and Homelessness Data Set: 

https://confluence.hl7.org/display/GRAV/Housing+Instability+and+Homelessn

ess+Domain
Gravity Use Cases

3. Gather and aggregate SDOH data for uses beyond the point of care

(e.g., population health management, quality reporting, and risk 

adjustment/risk stratification).

2. Document and track SDOH related interventions to completion.

1. Document SDOH data in conjunction with the patient encounter.

https://confluence.hl7.org/display/GRAV/Gravity+Use+Case+Package
eReferrals

Ability to electronically submit standardized documents to support 

referrals, track the status of referrals, and send consultation notes 

back to referring provider to close the referral loop. 

Example:
Current Elements in the IG for eReferral

§ Service Request 

• Evaluate use of FHIR BSeR Workflow Management 

Resources 

§ Service Delivery Report 

• Service request + status of procedure

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HL7 FHIR Resource ServiceRequest

http://hl7.org/fhir/servicerequest.html
HL7 FHIR BiDirectional Services_eReferral 

http://hl7.org/fhir/

us/bser/Workflow

ManagementResou

rces.html
Examples of Minimum Data for eReferral

§ That a referral was done 

§ When was the referral done 

§ Who did the referral 

§ Who was the recipient of the referral 

§ Who was the subject of the referral 

§ What kind of services were requested ✭

§ A way to determine what state the service request is in over 

time as it moves through a commonly accepted lifecycle/state - model 

§

✭

A way to determine what activities were actually provided 

as a result of that service request. ✭

✭= tricky

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https://trifolia-fhirdev.lantanagroup.com/igs/lantana_prod_hapi_r4/SDOHCC/

https://confluence.hl7.org/display/GRAV/Gravity+SDOH+FHIR+IG
FHIR IG Next Steps

§ FHIR IG development and balloting approach 

recently revised to meet accelerated timeline 

§ Changes to FHIR IG timeline and scope 

• Multiple SDOH domains in parallel to current approach 

(one domain at time) 

• Prioritization of screening and diagnosis SDOH data 

capture, exchange, and aggregation 

• Target FHIR IG ballot with HL7 in January 2021 

§ Test FHIR IG build at Sept. HL7 Virtual Connectathon 

• Sign up here: 

https://confluence.hl7.org/display/FHIR/2020-

09+Gravity+SDOH-CC+Track

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How to engage!
Join our Project!

§ Join the Gravity Project: 

https://confluence.hl7.org/display/GRAV/Join+the+Gravity+Project

§ Review and incorporate Food Insecurity Data Set 

definitions: 

https://confluence.hl7.org/pages/viewpage.action?pageId=55938680#FoodIns

ecurityDomain-FinalFoodInsecurityMasterList-Published16April2020

§ Review and comment on the Housing Instability and 

Homelessness Data Set: 

https://confluence.hl7.org/pages/viewpage.action?pageId=76157877#Housing

InstabilityandHomelessnessDomainHousingInstabilityandHomelessnessDataElements

§ Submit inadequate housing and transportation access 

data elements: 

https://confluence.hl7.org/display/GRAV/Data+Element+Submission

§ Commit to test the Gravity FHIR IG at the September 

2020 HL7 FHIR Connectathon: 

https://confluence.hl7.org/display/FHIR/2020-09+Connectathon+25
Questions?

Evelyn Gallego evelyn.gallego@emiadvisors.net

Twitter: @ egallego 

LinkedIn: linkedin.com/in/egallego/ 

Additional questions? Contact: gravityproject@emiadvisors.net

@ thegravityproj 

https://www.linkedin.com/company/gravity-project

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Phase 1 Submission
Rules and Terms and Conditions*

• Team lead must be a U.S. Citizen or permanent resident 

• Teams cannot include Federal entity or Federal employee 

acting within the scope of their employment 

• Federal grantees may not use Federal funds to develop 

their Challenge Submissions unless use of such funds is 

consistent with the purpose of their grant award 

• Federal contractors may not use Federal funds from a 

contract to develop their Submissions 

*Please see challenge.gov posting for more information

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Phase 1 Submission

Applications for Phase 1 are due Monday, 

December 14, 2020 by 11:59 PM EST 

• Submissions shall include one application 

package in PDF format 

• F ont size no smaller than 11 - point Arial 

• No more than 10 pages, not including the 

cover page, appendixes, or diagrams of the 

design.

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Application Outline 

Cover Page 

• Include team lead contact information (full name, email, phone).

Abstract

• Brief abstract describing the proposed solution and how the idea and 

concept design supports the problem presented in this Challenge. 

Project Narrative

• Describe existing methods or technologies that were used, 

combined, or built upon to design the proposed technology solution. 

• How the concept addresses each component of the judging criteria. 

• Describe the potential and likelihood for a successful demonstration 

and implementation.

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Application Outline cont. 

Team Member Roles 

• Brief description of relevant experience and expertise and their 

role and contribution to the team’s solution.

Appendixes 

• Use Case(s) that describe an example of how the proposed 

solution will enable referral solutions that will be implemented at 

the community and/or state level. 

• Technical architecture and workflow diagram(s) that clearly 

articulate how the proposed solution addresses interoperability, 

closed - loop referral processes, the exchange of data, and access 

to resource directories. 

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Judging Criteria

1. Level of Innovation 

– Forward - thinking solution that supports health 

and social integration and advances Health IT 

trends 

2. Partnerships and Collaboration 

– Inclusion of health IT developers, health care 

providers, health plans, state and local agencies 

that lead the aging and disability networks, and 

others with relevant technical expertise in data 

standards, architecture, and/or data analysis

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Judging Criteria cont . 

3. Scalability and Feasibility of Implementation 

– Consider the future state of interoperability and 

recognize emerging health IT standards 

§ Including standardization of bi - directional e - referral 

messages and community resource directories 

– Developed and supported open Application 

Programming Interfaces (APIs) for existing 

community resource directories

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Judging Criteria cont. 

4. Product Functionality and Usability 

– Describes functionality for planning assessments, 

closed - loop referrals, and data tracking through 

dashboard visuals 

5. Business and Technical Risk 

– Identifies potential business and technical risks 

with exchange and use of data that satisfies 

applicable legal and regulatory standards

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Summary - Phase 1 Submission

Ø Applications due Monday , December 14, 2020 

Ø Focus on concept & designfor interoperable, 

standards - based referral and analytics technology 

solutions that support health and social care 

integration. 

Ø Emphasis on forming ateam 

Ø Up to six prize winners will be announced in 

January 2021 with awards of $30,000 each

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Resources

Ø All details will be posted to: 

https://www.challenge.gov/challenge/innovativetechnology-solutions-for-social-care-referrals/

Ø New interactive webpage coming soon! 

Ø Contact: ami.patel@acl.hhs.gov

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Questions?