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Informational Only

This challenge is no longer accepting new submissions.

Innovative Technology Solutions for Social Care Referrals

Opportunity to create and modernize health IT platforms to foster connections between health care systems and community based organizations in support of holistic health and social care for older adults and people with disabilities.

Department of Health and Human Services

Total Cash Prizes Offered: $500,000
Type of Challenge: Software and apps
Submission Start: 07/13/2020 12:00 PM ET
Submission End: 01/06/2021 05:00 PM ET


At an unprecedented pace, Federal and state leaders, community based organizations, and all avenues of the health care system are expending their time and resources to respond to the COVID-19 pandemic. We at ACL recognize the need and are expanding the timeline of this new funding opportunity. The Challenge Competition will now begin in July. As a result of this crises, there is a greater need for enhanced, standardized data tracking and referral processes and an even more need to connect people with the right community resources and supports. This will continue to be a priority as we think about the resources necessary to address the effects of COVID-19.

Today’s Landscape of Health and Social Care Coordination 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. However, the existing technology solutions lack interoperability and scalability within and across communities. Since 2003, states and community based organizations (CBOs) have invested in robust resource directory and referral platforms through state No Wrong Door (NWD) System integration to streamline access to long term services and supports for older adults, individuals with disabilities, and their caregivers. Community Based Organizations may include Agencies on Aging, Aging and Disability Resources Centers, Centers for Independent Living or other aging and disability network agencies. State NWD Systems include a community based approach to person-centered planning and assessment, information and referral to state and community resources, and a governance structure that ensures these functions are available across the state. However, 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.

While some states have developed or are planning statewide technology platforms that enable social risk assessments and referrals from health care to community resources, there is a need for a more collaborative, multi-stakeholder approach that ensures the interoperability and scalability of such platforms. Examples of statewide approaches include:

  1. Oregon Health Leadership Council, HIT Commons:,
  2. Pennsylvania Request for Information for Statewide Resource and Referral Tool:

As is, there is duplicative spending across stakeholders as they independently contract for different referral vendors to secure community connections. As a result, community based organizations are faced with the burden of accessing multiple platforms to receive and act on referrals. Opportunities to manage populations across a continuum of care are also limited when individuals seek care from providers with differing platforms that lack seamless connections to critical health and social care.

The need for seamless exchange of referrals is also met with optimizing data on social determinants of health (SDoH) to ensure individuals get timely access to services and supports they need such as housing, nutrition, and transportation. Over the last several years, a variety of community led efforts are developing industry-wide standards to represent these components of SDoH and to enable exchange of person-centered data between health information technology platforms and CBOs. One such effort, perhaps the largest such activity in the SDoH space, is the Gravity Project. The Gravity Project 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. There is a need for health plans and systems to require and for technology vendors to uniformly adopt technical standards, which are being developed and tested. This include standards on the format, content and structure of SDoH data, community resource directories, and bi-directional exchange of referral messages.  The mid-to-long term goal is consistent implementation of standards for SDoH data, bi-directional exchange of referrals, and resource directories across technology platforms that serve health care and CBOs.

The Challenge:

The Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) is announcing 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 platforms. Participants are challenged with working collaboratively on enhancing scalable approaches to securely sharing 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’s 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 overtime.

To demonstrate value and achieve seamless network integration technical solutions are challenged with incorporating closed-loop referral and follow-up protocols to track and support individuals when they obtain services from any organization or health care provider within the network. Producing data on the individual, organizational, and regional levels about referrals, the prevalence of SDoH, and service utilization and outcomes guarantees opportunities to strengthen coordinated referral networks across CBOs, states, and the health care system. Technology-based platforms that enable linkages between healthcare providers and the existing ecosystem of community-based, social service organizations are challenged to more efficiently share standardized data to support referral processes and better informed decision-making, ensuring that individuals are seamlessly connected to resources that address their preferences, goals, values, and social determinants in ways that promote independence in the community for as long as possible.

Critical partners for designing solutions to this Challenge should include a team of key stakeholders. Strong preference will be given to teams that include state leaders across aging, disability and Medicaid programs (or their designees), community based organizations in the aging and disability networks, health IT developers, health care providers, health plans, and others with expertise in technical standards, interoperability and data analysis.

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

Phase 1: Concept & Design Submission (July - December 2020)

  • Form multi-stakeholder team and develop idea and concept designs that include functional enhancements, open standards, and technical specifications for enhancing health and social care integration.
  • Registration and Phase 1 Application submissions due Wednesday, January 6, 2021. See below for more information.

Phase 2: Proof of Concept & Demonstration (January 2021 - June 2021)

  • Participant teams will convene in-person or virtually to demo proposed solutions.

Phase 3: Implementation & Testing - (July - December 2021)

  • Implementation and real-world testing of designed approach.

What is a Challenge?

A challenge (also referred to as “prize challenge”, “competition,” “prize competition,” “incentive prize” or any combination thereof) allows the public to solve problems presented by federal agencies and receive awards for the best solutions. This boils down to three steps:

  1. Agency announces a problem to the public.
  2. Participants create and submit solutions to the problem.
  3. Agency evaluates solutions and awards prizes to the best ones.

This process may sound similar to grants or contracts, but challenges differ in small and significant ways. In grants and contracts an agency receives proposals to do work, chooses one and then pays the monetary award incrementally as the work is done. In challenges, an agency generally selects winner(s) after assessing work that has been completed. In more complex, multi-phase challenges, phase winners may be selected progressively as development stages are completed.

Unlike contracts in particular, which provide detailed and comprehensive specifications of the work that needs to be done, challenges define a smaller set of requirements, which allows participants to bring more of their own creativity to solutions.This can be advantageous when a problem can be solved many different ways, including ways that the agency is not even aware of. The open-ended approach can entice participation from those who may not have direct expertise in the problem subject matter area but can lend expertise from their diverse backgrounds.

Challenges can serve multiple goals beyond sourcing solutions to problems, including:

  • Signal interest in an area that you think markets should be doing more to serve
  • Reach wide communities of experts
  • Deliver messages to the public in a fun, interactive way
  • Generate interest in new services, data or technologies your agency provides
  • Develop public buy-in for agency initiatives

For more information, please visit:


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


To be eligible to win a prize under this challenge, an individual or entity may participate as part of one or more teams. Team formation is strongly encouraged, and teams are not limited in the number of members. Each team must designate a captain who must be a U.S. citizen or permanent resident who is responsible for all correspondence regarding this Challenge. An individual or entity:

  • Shall have registered to participate in the competition under the rules promulgated by the Administration for Community Living;
  • Shall have complied with all the requirements under this section;
  • In the case of a private entity, shall be incorporated in and maintain a primary place of business in the United States, and in the case of an individual, whether participating singly or in a group, shall be a citizen or permanent resident of the United States;
  • May not be a Federal entity or Federal employee acting within the scope of their employment (all non-HHS federal employees must consult with their agency Ethics Official to determine whether the federal ethics rules will limit or prohibit the acceptance of a COMPETES Act prize);
  • Shall not be an HHS employee;
  • Federal grantees may not use Federal funds to develop submissions unless consistent with the purpose of their grant award; and
  • Federal contractors may not use Federal funds from a contract to develop COMPETES Act challenge applications or to fund efforts in support of a COMPETES Act challenge submission.

Terms and Conditions

  • An individual or entity shall not be deemed ineligible because the individual or entity used Federal facilities or consulted with Federal employees during a competition if the facilities and employees are made available to all individuals and entities participating in the competition on an equitable basis.
  • 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 and specifically requested to do so due to the Challenge design, and as announced on
  • Federal contractors may not use Federal funds from a contract to develop their Submissions or to fund efforts in support of their Submission.
  • Multiple entries are permitted. Each solution must be sufficiently novel and unique and not be a minor modification of a prior submission.
  • A demonstration of the developed technical solution must be included in your submission, as per phase two conditions, either via weblink, or as a downloadable app from a website. If a login is required, demo accounts with password should be provided which will enable evaluators to access all parts of the product. If there are different interfaces, separate logins should be provided.
  • Participants must also agree to assume any and all risks and waive claims against the Federal Government and its related entities, except in the case of willful misconduct, for any injury, death, damage, or loss of property, revenue, or profits, whether direct, indirect, or consequential, arising from my participation in this prize contest, whether the injury, death, damage, or loss arises through negligence or otherwise.
  • Participants are required to obtain liability insurance or demonstrate financial responsibility in the amount of $0 for claims by a third party for death, bodily injury, or property damage, or loss resulting from an activity carried out in connection with participation in a challenge.
  • Participants must also agree to indemnify the Federal Government against third party claims for damages arising from or related to Challenge activities.
  • Contestants to this Challenge competition must agree to be bound by the rules of the Challenge agree that the decision of the judges for this Challenge are final and binding, and acknowledge that their submission may be the subject of a Freedom of Information Act (FOIA) request and that they are responsible for identifying and marking all business confidential and proprietary information in their submission.

The Administration for Community Living reserves the right, in its sole discretion, to (a) cancel, suspend, or modify the Challenge, and/or (b) not award any prizes if no entries are deemed worthy.

Judging Criteria

Judging Panel

The Judging Panel will be composed of federal and/or other technical and subject matter experts.

Judging Criteria

  1. Level of Innovation and Value to Stakeholders

    • Clearly and concisely identifies the problem and its significance to the stakeholder team
    • Proposal bridges the gaps between community members and products, services, and information
    • Forward-thinking solution that leverages upcoming and future technology trends including existing and developing content
  2. Partnerships & Collaboration

    • Strength of the team that is inclusive of key stakeholders. Key investors include 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
    • Inclusion of co-leadership roles from state and/or community leaders and health care organizations
    • Commitment to implement proposed open standards through collaborative governance amongst key stakeholders
  3. Scalability and Feasibility of Implementation

    • Proposal has robust design and plan for open Application Programming Interface (API) standards for existing community resource directories

      • Clear technical design of an open API standard for community resource directories using the Human Services Data Specifications (HSDS)
      • The proposed open API standards for community resource directories can be easily adopted and implemented by existing and new directory platforms
      • States and CBOs can easily integrate with the proposed open API standards for community resource directories
    • Inclusive of the Gravity Project identified terminology (LOINC, SNOMED-CT, and ICD-10) and technical standards (HL7 FHIR) to represent and exchange SDOH data

  4. Product Functionality and Usability

    • Proposal has broad applicability (i.e., across conditions, populations, health IT environments/technologies/platforms)
    • Inclusive of planning assessments
    • Look up and retrieval of community resources through a standardized community resource directory
    • Closed-loop referral management
    • Analytics and dashboards visuals to track service delivery, and outcomes
  5. Identification and Mitigation of Business and Technical Risk

    • Identifies potential business and technical risks associated with closed-loop referral processes
    • Inclusive of appropriate management and technical controls to ensure that the storage, exchange, and use of data satisfies applicable legal and regulatory standards
    • Valid operational security and privacy measures are addressed

How To Enter

Phase 1 Submission Requirements

Applications for Phase 1 of this Challenge are due by Wednesday, January 6, 2021 by 05:00 PM EST. The identified Official Representative (individual, team or legal entity) may apply for this Challenge by registering and submitting an application to The application for Phase 1 of the Challenge shall meet the following requirements:

  • All submissions must be in English using simple, straightforward and concise language.
  • Solvers must not use HHS, ACL, or other government logos or official seals in the submissions and must not otherwise give an appearance of Federal government endorsement

The official Phase 1 application form is available online and can be accessed by registering at Solvers will be asked to submit the following information in the official online application:

  • Team Information: Team name, primary contact information, and information on team collaboration.
  • Abstract: Brief abstract describing the proposed solution and how the idea and concept design supports the problem presented in this Challenge.
  • Project Scope: Description of the geographic region the proposed solution will cover.
  • Project Narrative:

    • Provide an overview of the design and concept of the proposed solution and how it addresses the problem(s) described in this Challenge.
    • Describe how the proposed solution brings value to the team of stakeholders. (See description of judging criteria #1.)
    • Describe the existing and/or new methods of technologies that were used, combined, or built upon to design the proposed solution, including how the proposed functionalities meet the criteria listed in judging criteria #3 and #4.
    • Describe the potential and likelihood for a successful demonstration and implementation if the proposed solution is selected for proceeding phases of the Challenge. Include how the success of the proposed solution will address the business and technical risks described in judging criteria #5 and how the team defines and measures a successful solution.
    • Provide a timeline for getting to a complete solution, citing milestones and goals. Consider including key points towards a successful solution, such as partnerships, technical tasks, and roll out.
  • Team Member Roles: For each individual, include a brief biographical sketch of relevant experience and expertise and their present affiliation (institution/organization/company) and include their role and contribution to the team’s solution. (See description of judging criteria # 2.)
  • 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 approach and/or specifications, which may include both high and low level technical details, such as architecture, workflows, schemas, data exchange standards, and API endpoints, for the following:

      1. Technical approach and/or specifications for establishing open community resource directories using the Human Services Data Specifications (HSDS).
      2. Technical approach and/or specifications for the team’s approach for incorporating and standardizing SDOH data content using the Gravity Project’s identified terminology.