CloseTheCircle® For Social Determinants

Although significant progress has been made in narrowing the gap in health outcomes, disparities persist. While no single organization can solve the deeply rooted inequities, Nxt Wave Founders partnered with HealthOPx to amplify the innovative potential packaged solution to help solve for health inequities.  Restrictions in eligibility and use of support continue.   The Supplemental Nutrition Assistance Program (SNAP) offers nutrition assistance and reaches far more households because eligibility is based on income versus having restrictions by family type. In Chicago 197,795 households received SNAP in 2017. Average monthly benefit received by Illinois households was $240.50. The Temporary Assistance for Needy Families (TANF) program provides direct financial assistance for the poorest families with children. Unfortunately it reaches few families in need, and for those it does reach the financial support is meager.  When taken together TANF and SNAP just barely get families who receive both to half of the poverty line.

To help eradicate racial and social inequities as a public health threat, it is important to help address health inequities impacting communities of color. For the United States, health disparities take many forms, including higher rates of chronic disease, increased burden of illness, lack of access to basic care and significant social and economic barriers to initiating and maintaining treatment such as loss of income, access to workforce development, childcare, eldercare, transportation, food security and housing.

• Heart disease and cancer are the leading causes of death across race, ethnicity and gender. 
• African Americans were 30% more likely than white people to die prematurely from heart disease, and specifically, African American men were reported twice as likely as white people to die prematurely from stroke.
• Another study shows that African Americans are 2.8 times more likely than white people to screen positive for peripheral arterial disease, and have 1.5 times the risk of limb loss as a result of the disease compared to their white counterparts. 
• Adding to the urgency of these challenges, the U.S. population is becoming more diverse – with people of color projected to account for over half of the population in 2050.

This is packaged solution that complement each other well.

HealthOPx’ main beneficiary is Community-Based Organizations (CBOs), who sign up on a service-based platform to deliver services to patients and at-risk populations.  When CBOs deliver these services, data collected gets sent to contracted suppliers such as health systems, insurers and payers. They provide financial incentives to CBOs. HealthOPx delivers those incentives to CBOs on a performance basis, with an AI/Machine Learning algorithm plugged in to measure ROI.

CloseTheCircle®’ main beneficiary is a Network of Care (NoC) living within a civic infrastructure. A NoC member is a clinician, social worker, nurse, etc. using a universal application tool.  This tool streamlines local public assistance applications and integrates data aspects of population health management to identify gaps within communities of color and provide actionable insights to deliver interventions and resource development.  When the NoC can overall function more efficiently and in real-time, the value of care increases. Relationships with Residents and CBOs improves.  Local Officials follow reports in a timely manner and access quality data to work with service providers and convey incentives, savings, and discounts that directly benefits consumers by improving their access to quality and affordable treatments and related products.

Community-Based Organizations (CBOs) cannot afford to move at the pace of innovation. When CBO’s deliver a measure of preventative care or intervention through HealthOPx's free (service-based platform) it feeds back into the algorithm and we are able to calculate how much they decreased the risk of X adverse health event or how they affected X health improvement initiative. This platform allows for more funding to flow through to CBO's who can help more under-served in their community. We help bridge the gap in data, financial barriers, and coordination that CBO's have. 

State/City Officials provide important resources to low income residents, including utility discounts, food assistance, and childcare assistance.  Although these programs are available online, the application and processing for these programs can benefit from creating efficiencies for residents and their case managers when accessing these programs. Public Officials have a vested interest in improving data quality and access.  Local Health Authorities can monitor the status of public assistance data in real-time from everywhere with or without internet connection.  For them, it means access to supporting documentation across multiple agencies reducing cost. 

Residents of color particularly are under-served. With CloseTheCircle®, residents can apply to public assistance programs at once without needing to re-qualify for each benefit.  People with low and middle-incomes are financially savvy in ways that are often underestimated, but despite this are on thin ice financially. Despite doing all the right things, they are caught in a trap that is very hard to escape. The COVID-19 Pandemic highlighted systemic inequalities rooted in historical and contemporary structural inequalities. These hardships are taking both a personal toll and a community toll.  Wages falling behind and jobs increasingly structured in ways that foster precariousness instead of supporting stability. Further, safety net supports are inadequate to meet growing challenges. 

Case Managers are participatory agents in a Network of Care (NoC) that access multi-dimensional and inter-relational data to communicate with residents and make referrals to peers via text messaging and video-chat integrations. Case Managers, Front-End and Last-Mile Workers are stretched thin keeping up with red-tapes and bottle necks.  We need to provide them with better systems to outreach more people in need. The safety net programs privileges some groups over others, valuing the well-being of those who work, who are married or at least widowed, and who have children. Those who are left out, considering undeserving of needed support, are those who cannot or do not work, who are single parents, and who do not have children. This is rooted in, and under-girds, racial inequity in our nation. Policies and narrative equates having a low income as a moral failing rather than a societal and structural one. 

Alignment with Dimension of The Challenge. Strengthen disease surveillance, early warning predictive systems, and other data systems to detect, slow, or halt future disease outbreaks.

We need to provide better systems to outreach and qualify more people in need. Safety net programs privileges some groups over others, valuing the well-being of those who work, who are married or at least widowed, and who have children. Those who are left out, considering undeserving of needed support, are those who cannot or do not work, who are single parents, and who do not have children. 

We are currently on the prototype stage due to the fact that we have already launched the beta version of the application to be used in Flint, MI. by Latinos United in Flint and Genesee County Free Clinic. From the feedback provided by the community and the community-based organization we worked with (Latinos United in Flint) we decided to create another version, which is the platform described in this proposal. In this version, patients do not need to download an app or have WiFi to receive services. We also made the interface and user flow much simpler to use and navigate for community-based organizations and healthcare entities. In July, we will be testing this new platform with users in Washington D.C. with some D.C. CBO's and CareFirst BlueCross BlueShield. We will also be testing it with our existing pilot in Flint, MI. with Latinos United and University of Michigan Flint. 

CloseTheCircle® - While many efforts have turned to creating automatic pre-filling options for specific government entities such as tax filing with the IRS, we don't see enough innovation in streamlining processes with a resident-centered approach.  Low-income families, their Network of Care, local officials and service providers will benefit tremendously from CloseTheCircle® approach and bringing Ai elements to streamline processes that have not been updated for more than a century.  

HealthOpX is taking an innovative and personable approach to tackling costs and improving health of at-risk patients with our mobile/web app that easily creates value-based relationships between community-based organizations, health systems, and health insurance companies. Our differentiator is easily creating and formalizing these relationships. These value-based relationships give funding and sustainability to community-based organizations by establishing contracts that CBO’s have the trust, experience, and infrastructure to carry out. This system brings in more patients for health systems, cuts preventable patient costs for health insurers/health systems, and improves the HEDIS and star ratings of the health insurance companies involved. Our A.I./ML algorithms calculate ROI from the perspective of the government, health insurer, provider, and community-based organization to create true value-based relationships. This new system brings money back into communities through CBO's and easily facilitates the way that CBO's, hospitals, government, and health insurers interact to engage at-risk populations in the community.

HealthOpX is currently working in Flint, MI and Washington, D.C. Our ultimate end users that we meaningfully want to effect, are the underserved communities and at-risk patients. In one year, in Washington D.C. we plan to expand our pilot program of 50-100 patients to the full 75,000 medicaid population that is under CareFirst BlueCross BlueShield. In 5 years we plan to be working with medicaid plans in 5 different states with a total of 5.6 million people. 

Nxt Wave Founders has identified 34 City Mayors serving 16 Million of Americans across the country that are looking for solutions like CloseTheCircle® prioritizing the following markets to serve in the first year:

• Evanston, IL
• Jackson, MS
• Richmond, VA
• Mount Vernon, NY
• Alhambra, CA
• National City, CA
• Houston, TX
• Jacksonville, FL

HealthOPx has identified markets including:

• Flint, MI
• Detroit, MI
• Washington, D.C.

In three years, national market penetration should be completed.  

In five years, our scale and growth will be global.

As referenced before, success of this packaged solution will be dependent on addressing the barriers to equitable access to health care across the patient journey including the patient/physician level and clinical encounter.  

The packaged solution platforms generate a wide range of data and analytics that serve to gauge the project's  performance. The CEO of Nxt Wave Founders and the CEO of HealthOPx will report weekly updates  and monthly briefings to the stakeholders using routine data to report on key performance indicators, such as: # of people in need outreach and qualified, growth on eligibility, transition to jobs, economic mobility, and more. 

Nxt Wave Founders is a 501(c)(3) hosting The CloseTheCircle® Solution.

HealthOPx is a for-profit entity, social enterprise or other.

If awarded, CloseTheCircle® will dedicate: 

• 1 Full-Time Project Manager.
• 1 Full-Time Fellow Researcher.
• 1 Part-Time Administrator.

HealthOPx will dedicate:

• 1 Full-Time Project Manager
• 1 Full-Time Product Manager
• 1 Full-Time Software Developer
• 1 Full-Time Software Tester

Wesley Ma leads HealthOpX. HealthOpX cofounders are all 2nd generation Americans who had to help their parents navigate the healthcare and government system. Growing up, their families had to rely on their community to help answer questions they didn't know. The perfect solution that we came to, was to bolster up the community-based organizations, get them more funding, and allow them to have a larger role in healthcare. Our team collectively has 10+ years of UI/UX experience, 5+ years of AI/Machine Learning experience, and 15+ years of software development experience.

Luisa Bracamonte leads Nxt Wave Founders (NWF) leads Nxt Wave Founders (NWF) with her experience as a program software development manager, startup founder, and social impact entrepreneur.  Previously, she led $12M software projects that launched SAP products into global financial platforms for State Farm Insurance, a $18M Tele- communication services serving millions of global customers for Crown International. She envisioned a convenient way for herself and fellow founders to scale their impact through the development of fair machine learning, build community and create jobs in areas with some of the highest poverty rates by hosting The ScoutZ Lab2Market (SL2M) Hub's Initiatives.

HealthOpX cofounders are all racially ethnic minorities. 2 of our 3 directors are either women or people of color. Goals we have include having C-suite and director level employees more than 50% BIPOC or women-led. Because so many of the people we serve are at-risk populations or come from underserved communities, we want our team to have a personal connection to them.

At Nxt Wave Founders, Inc (NWF) a diverse, inclusive, and equitable workplace is one where all employees and volunteers, whatever their gender, race, ethnicity, national origin, age, sexual orientation or identity, education or disability, feels valued and respected. We are committed to a nondiscriminatory approach and provide equal opportunity for employment and advancement in all of our departments, programs, and worksites. We respect and value diverse life experiences and heritages and ensure that all voices are valued and heard.

We’re committed to modeling diversity and inclusion for the entire arts industry of the nonprofit sector, and to maintaining an inclusive environment with equitable treatment for all.

CloseTheCircle and HealthOPx are applying to the MIT Solve Global Challenge for three main reasons:

1) Gain visibility among foundations and investors seeking to support minorities and moonshots.

2) To secure a $10,000 winning award to augment funds to our ongoing fundraising efforts.

3) Access to mentors and coaches in areas of software protection and security, inclusion and diversity, scale-up, investment and growth. 

Every day, we are inspired and motivated by our mission and we don't cease to bring the sweat equity beyond our limitations.  And we don't stop thinking what we could accomplish if we had the money to hire more people like us. who can help us bring our innovative solutions to millions and millions of people across the country and overseas.

Wesley?

We seek introductions to Public Health and Health Care Programs offered by MIT and alliances to develop a systemic, data-driven  methodology  that  integrates  advanced  statistical  analysis, mathematical models, and controlled field experiments to promote technology adoption and test the impact of the platform on behavior in the public assistance and healthcare delivery supply chain and the resulting health outcomes.   

As early-stage entrepreneurs, support on operational functions such as legal, accounting and marketing  that can further our passion for automation and innovation, are all welcome and appreciated.

Wesley?

MIT Solve Mentors and Members that aligned well with our project.

We can contribute to The RWJF Culture of Health Prize Impact by joining the effort to elevates U.S. communities that have placed a priority on health and are creating powerful partnerships and deep commitments that enable everyone to live healthier lives.

Our packaged solution can provide notable benefits to the communities served by The Innovation for Women Prize facilitating a Network of Care that could guide women through the application for multiple Public Assistance Services.  

While artificial intelligence has the potential to make healthcare more accessible and efficient, it also is vulnerable to the social, economic and systemic biases that have been entrenched in society for generations.

The first step to keeping AI from amplifying existing inequalities is understanding the bias that can creep into algorithms and how to prevent it through careful design and implementation.  We are committed to practicing Fair Technology Development by auditing our algorithms on a regular basics.

With half the world lacking access to basic, essential health services, renewing primary healthcare, which has been underfunded for decades, and placing it at the center of efforts to improve health and well-being is critical to achieving global health priorities. Frontline health workers—especially nurses, midwives, and community health workers—are often the first and only link between communities and health systems. They are key members in the Network of Care we are proposing to nurture through our packaged solution.  Leveraging a people-first model, the Center focuses on equipping nurses, midwives and community health workers across the globe with the skills, resources and support they need to improve quality of care and strengthen primary and community-based health systems.