Success Story

Transforming Assessments and Referrals for NJ Residents

Project aims to transform assessments and referrals for NJ residents in need of health and social services – and to be a model for pediatric care


Every month for the year since her husband died, Wanda has had to decide whether to pay the electric bill or, instead, buy groceries for herself and her two children, 11-year-old Will, who is on the autism spectrum, and 7-year-old Sylvia, who has asthma. Wanda’s financial dilemma is toughest during winter, when utility bills soar for her small one-bedroom apartment in Asbury Park, NJ. Nevertheless, she always makes the same decision. She chooses food.

Family sitting on bench

Integrated Care for Kids

A project funded by the Centers for Medicare & Medicaid Services, called Integrated Care for Kids (InCK), aims to significantly improve health outcomes for at-risk pediatric Medicaid recipients like Will and Sylvia by identifying them far earlier, and then delivering integrated care coordination and case management that connect them to healthcare and human services across an array of partner organizations (e.g., schools, housing, food, and child welfare, and mobile crisis-response services).

New Jersey InCK one of seven such projects nationwide, is a consortium led by Hackensack Meridian Health (HMH), the Visiting Nurse Association of Central Jersey, the NJ Health Care Quality Institute, and the state’s Medicaid agency. While NJ InCK is focusing on Ocean and Monmouth counties, the goal is to create a model that can be replicated across the state, aligning payment with care quality while addressing core child-service domains that address the social determinants of health (SDOH).

Identifying Two Partners

To accomplish its goals, NJ InCK’s team identified two partners – MayJuun and Open City Labs (OLC) – whose technological approach to needs assessment and closed-loop referral management software meet providers and patients “where they are.” That is, their solutions are both accessible to patients and interoperable with electronic health records (EHRs), while also building on existing community assets such as NJ 211’s statewide directory of community resources.

MayJuun’s Health Story

HealthStory will be used by NJ InCK and 40 partner organizations to screen children and youth from a pool of over 140,000 Medicaid recipients across 17 age groups. MayJuun’s solution harnesses over 570 unique Health Level Seven (HL7®) Fast Healthcare Interoperability Resources (FHIR®) resources. Patients, or their parents are able to complete assessments (such as PRAPARE) on almost any mobile device whenever and wherever they choose. Once complete, the results are scored to assess patient needs and identify those most at-risk.

MayJuun was selected to deliver HealthStory in part because it will make NJ InCK’s assessments accessible to patients in different languages on mobile devices (IOS and Android), as well as on the web. These assessments leverage the increasingly accepted standard for healthcare interoperability, FHIR.

Doctor examining child patient

“As a practicing doctor, I was frustrated by a lot of the software throughout the industry. So, to lower both the technical and monetary barriers for building more-usable and attractive digital health apps, we created and open-sourced FHIR-FLI, a framework that combines FHIR with Flutter, an open-source framework from Google.”

John Manning

John Manning

CEO of MayJuun

Rapid Open-Source Application Development

MayJuun’s HealthStory is developed using Google’s open-source framework Flutter. Flutter supports rapid development of applications on multiple platforms, including iOS, Android, Progressive Web Applications, Windows, MacOS, Fuschia, and Linux from a single code base. The FHIR-FLI framework has been adopted by an international community of open-source software developers and is currently being used in the US, Canada, Germany, Italy, India, Mexico, and Argentina.

“While technology is never the entire solution, it should be a help, not a hindrance,” added MayJuun CTO Grey Faulkenberry, who is a practicing physician boarded in Internal Medicine, Pediatrics, and Clinical Informatics. “To help remove barriers, we created a process to streamline the creation of almost any type of question, from any type of questionnaire, in any language, which can be almost instantly structured using FHIR.” MayJuun’s solution then dynamically displays these questions, and they may be updated easily at any time.

Flutter coding graphic

Open City Labs’ Navigator 360

While a variety of referral directories have been developed around the country, interoperability across directories – in order to present a comprehensive picture of clinical and human services, as well as referrals across software systems – has remained elusive due to a lack of widely embraced standards.

“It was important to choose a scalable solution that leverages the Gravity Project’s standards for identifying and addressing patients’ social needs, so that clinicians can stay in their workflow. Switching between different software systems for different tasks is inefficient”

Steven Kairys

Steven Kairys

Chair of Pediatrics for HMH and Principal Investigator of NJ InCK

The leaders of both OCL and MayJuun are active contributors to and participants in the Gravity Project and a variety of other standards development bodies. In July 2021, the Gravity Project coded terminology standards were included in the Office of the National Coordinator for Health IT (ONC) U.S. Core for Data Interoperability version 2.

Contracting with NJ 211

NJ InCK contracted with NJ 211 for OCL’s referral management system, Navigator 360. NJ 211 is a nonprofit information and referral service that is funded by the United Ways of NJ and state government. By supporting referrals over multiple standards (e.g., Direct Secure Messages and Gravity’s SDOH Clinical Care FHIR standard), providers using OCL’s Referral Management App, Navigator360, can make or receive referrals across systems, reaching their referral recipient in their system of record. This includes every certified electronic health record, enabling reach to over 300,000 organizations and 2.91 million addresses nationwide.

The solution is accessible to patients via OCL’s CARE360, giving them their own customized version of the NJ 211 Directory while being interoperable with electronic health records, and also building on existing community assets such as NJ 211’s statewide directory of community resources. Furthermore, clinical and human service providers will be able to add their own organizations’ service data to both Open City Labs’ federated directory and the DirectTrust National Directory.

Digital health graphic

“In order to deliver the best care for patients in any community, we need a comprehensive picture of the clinical and human services that serve that community. Our federated directory model grew out of the desire to build on existing community assets, like NJ 211’s database. By meeting providers where they are and not taking them out of each system of record, we make it easier to connect patients to the services they need and to close the referral loop.”

Matt Bishop

Matt Bishop

CEO of Open City Labs

After being selected to work together on the NJ InCK project, MayJuun and OCL entered the federal Administration for Community Living (ACL) Social Care Referrals Challenge as Team FHIR-FLI. In December 2021, they were selected as a finalist in the Phase 2 competition, along with three other teams.

Strength in Collaboration

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