Abstract: Vulnerable and underserved populations such as ethnic and racial minorities, the poor, the LGBTQ community and those with physical or intellectual disabilities, often suffer the greatest health risks while facing significant barriers to receiving healthcare. While biological and clinical risks influence outcomes, sociocultural and socioeconomic factors also create major barriers to receiving healthcare services, at an individual, community and population level for these populations. These social determinants of health (SDOH), such as transportation, literacy, and finances, can severely limit participation in health programs designed for the general population. Diabetes Prevention Programs (DPP) are a good example of a lifestyle change protocol that is proven to reduce the risk of type 2 diabetes by half for at-risk pre-diabetic patients by encouraging weight-loss. But, despite the effectiveness of the program, more than 50% of participants drop out before completing this year-long lifestyle change program, severely limiting the program’s success. This is in part due to the fact that programs like DPP take little account of the SDOH limitations faced by underserved and vulnerable populations that it is meant to help. This lack of support at the individual and community level combined with the fact that healthcare institutions are not designed for, nor economical, in supporting patient health outside the medical facility where it is most needed. This creates a gap in healthcare service that current systems cannot overcome. Viora is closing this health services gap with a digital wraparound system that extends care management workflows at healthcare organizations by engaging underserved patients at home to facilitate better outcomes in programs like DPP. By using risk stratification based on SDOH and lifestyle factors, each DPP participant can have tailored interventions that consider their socioeconomic and sociocultural characteristics. The Viora TIPS system uses a simple 2-way communication to interface between patients, coaches, health providers, and underutilized community services, facilitating and supporting patient self-management and completion of the DPP program. In Phase I, Viora Health completed work followed by a human subject study with underserved subjects and community-based partners. Completion of Phase I demonstrated feasibility of Viora system prototype and collected feedback to improve system components. In Phase II, Viora will automate and integrate features from the Phase I work to provide automated on-boarding based on risk stratification models completed in Phase I, to facilitate a more effective personal intervention plans; automate distribution of personalized content during the DPP program, and track progress on closing SDOH gaps. The completed system will then be evaluated in a case controlled human subject study of a minority population participating in a DPP program. This work will be the final step before a minimum viable product can be released to the market for commercialization.

Narrative: Vulnerable and underserved populations often suffer the greatest health risks while facing significant barriers, largely due to social and behavioral factors that hinder continued participation in disease prevention and management protocols. Viora Health’s wraparound digital health support system will support public health scaling of evidence-based protocols by using technology to identify and rank such risks while leveraging existing community based resources to support patients in mitigating these factors.