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In AHRQ's Digital Solutions to Support Care Transitions Challenge competition, ´óÏóÊÓƵsought applications proposing personalized, high-tech ways to ease administrative and information management burdens, and support patient activation and engagement, especially among Americans diagnosed with multiple chronic conditions and those that may have low health literacy or limited English language proficiency.

About the Challenge

When a person needs care for multiple chronic conditions (MCCs), they often encounter problems such as—

• Discharge summaries are often not sent in time to inform care in the critical post-discharge period.
• Hospital discharge summaries are generally sent to only the primary care provider. However, people with MCC often have several key clinicians who don't necessarily coordinate with each other.
• Discharge summaries that cannot be integrated into ambulatory providers' electronic health records (EHRs), to provide critical information when it is needed.
• Hospitals and skilled nursing facilities are unable to arrange services needed in advance of discharge (e.g., durable medical equipment) to meet the needs of people living with MCC (as described in Coleman's Care Transitions Program or Naylor's Transitional Care Model). Digital health solutions are not used to make such handoffs more effective and efficient.

This challenge encouraged solvers to develop interoperable health information technology (IT) solutions to engage patients with MCCs and family caregivers during care transitions to home, as well as link them to community resources.

Timeline and Prize Structure

´óÏóÊÓƵhosted this Challenge as a 2-phased competition from February to October 2020. Phase 1 solicited ideas (i.e., solution proposals) for digital solutions that reduce burden in care transitions for individual with MCC.

Total cash prize: $125,000

Phase 1: Proposal of Innovative Models. Phase 1 prize $50,000 ($10,000 per semifinalist; HHS made five awards).

Semifinalist teams from the first phase developed and tested their solutions on a small scale. Teams received guidance and resources for development and testing, and created Phase 2 plans to demonstrate their approach. At the end of Phase 2, teams submitted their findings, demonstrated their solutions, and showcased their progress to compete for the grand prize.

Phase 2: Small-Scale Testing of Models. Phase 2 prize $75,000; HHS made two awards.

Review Process/Evaluation Criteria

Phase 1 Evaluation Criteria:

Challenge submissions were reviewed by a committee of experts with requisite competencies based on the below criteria, which the solver submission shall demonstrate. The advisors used a Likert-type scale to assign numeric ratings; the criteria were weighted as follows: Understanding of the Problem (30%), Tool [Prototype or Currently in Use] (40%), Linking to needed services (30%).

Phase 2 Evaluation Criteria:

Challenge submissions were reviewed by a committee of experts with requisite competencies based on the below criteria, which the solver submission shall demonstrate. The advisors used a Likert-type scale to assign numeric ratings in three categories; the criteria were weighted as follows: Understanding of the Problem (20%), Tool [Prototype or Currently in Use] (60%), Linking to needed services (20%).

All applications were reviewed by at least two Expert Advisors who scored them based on the five evaluation criteria. The Expert Advisors also provided comments about the application.

The scores/comments were compiled and a ranking summary provided to ´óÏóÊÓƵstaff. The ´óÏóÊÓƵstaff used those scores/comments to review a shorter list of the applications and then make a final decision of the semi-finalists for Phase 1.

Challenge Winners

´óÏóÊÓƵawarded $50,000 for first place and $25,000 for second place to two challenge winners for prototype development.

CareLoop

CareLoop's Safe Discharge Communication Pathway, empowered by the interoperable CareLoop® platform, ensures safe transitions in care for patients and care team members. The team applied an agile approach to person-centered design, rapid prototyping, and advanced informatics methods, HL7/SMART on FHIR and only HIPAA-compliant tools and services, with a modern asynchronous interoperable communication platform. The innovative solution provides closed-loop and context-specific communication between the patient and family caregivers and hospital, primary care, and community partner care teams throughout the hospital discharge to home transition in care. In this Challenge, design partners addressed the information-sharing needs, burdens, and gaps for patients with three emblematic chronic conditions (congestive heart failure, hypertension, and depression) and showed a clear commitment to diverse audiences, especially those with low health literacy and low English-language proficiency. The team specifically accounted for the COVID-19 public health emergency and the consequences of social isolation on care transitions, switching from in-person to virtual design sessions to recruit representative focus group participants.

CareLoop will continue to enhance the Discharge Pathway with user-centric modifications to address users who are patients or family caregivers with low health literacy or limited English proficiency. The team prioritized five design ideas that they will continue to build out: (1) testing data-driven personalization triggers, (2) creating an educational resource library for patients and family caregivers, (3) creating an assessment library for clinical teams, (4) improving processes for collecting and analyzing co-design feedback, and (5) gaining feedback on perceptions of intelligent virtual assistants.

WeWa.life

WeWa.life is a personal health navigator platform designed to address underserved individual and virtual health community needs. An intuitive phone app enables health consumers to be in control, informed, entertained, engaged, and activated around the most important thing in their life—their health. The WeWa.life Cloud platform provides a single point of integration with existing health consumer systems using open APIs and an interoperable system architecture. Our WeWa.life developed a user-centered design solution incorporating behavioral science and interoperable digital health technology to provide a hyperpersonalized approach to managing health and improving medical outcomes along six Health Goal pathways. The solution is well-grounded in existing literature regarding healthcare costs, adherence and medication safety, and health information technology policy and focus on three key aspects of care transitions that are similarly well-grounded in existing evidence: discharge instructions, medication management, and followup care.

WeWa.life will continue their progress to finalize the commercial version of their app, develop a Spanish-language interface for WeWa.life, expand the web interface and backend portal, add additional health pathways (goals), continue developing the digital voice assistant, and develop large-scale real-world trials.

Phase 1 prize $50,000 ($10,000 per semifinalist) was awarded to each of the following: