A team of researchers from the University of Utah are among the five finalist teams in AHRQ's Digital Solutions to Support Care Transitions Challenge. The challenge is intended to, “to develop interoperable health IT solutions that engage patients and family caregivers during transitions from inpatient hospital care to home, especially among Americans that may have low health literacy or limited English language proficiency.” The University of Utah team includes Andrea Wallace (Health Systems and Community Based Care), Ken Kawamoto (Biomedical Informatics Research), Guilherme Del Fiol (Biomedical Engineering), Roger Altizer, Jesse Ferraro (Gaming and Applications) and United Way 211 partners. The team states the following about their project—called the “Goin Home Toolkit”—that landed them a finalist position: “Our objective is to better support the needs of patients returning home after hospitalization by engaging them in anticipatory planning and connecting them and those in their support network—family, friends, neighbors, outpatient providers—to community-based resources. “The Going Home Toolkit electronic resource planner will utilize connections to the United Way 211 referral service and the patient's personal health record to enable efficient communication of post-discharge needs, referrals to supportive services, and systematic capture of patients' supportive resource information to better understand care transition needs. “The Going Home Toolkit is organized around common needs after hospital discharge, such as transportation, medication, errands, meals, housework, personal care, billing and insurance, ongoing information, and support.” If the project advances, the University of Utah finalist team stands to garner additional funding a promotion via AHRQ to potential vendors. The teams in this phase will submit their finding in October of 2020.