The implementation of the tool has been delayed due to technology governance issues and requests for changes in the end user design.

The purpose of this study is to determine the impact of embedding a risk-stratification tool, designed to identify patient needs for services that address social determinant of health related needs, in a commercial electronic health record system (EHR).

Social determinant of health related needs and social risk factors complicate care delivery and drive health and well-being. Social needs are common among undeserved patient populations, but health care providers are often not equipped to routinely identify and address patients in need.

Using a combination of health information exchange, electronic health record, and aggregate datasets the investigators developed predictive algorithms to identify patients a highest risk for a need for a referral to a social worker, dietitian, behavioral health, or other wraparound service provider. Risk scores are available to primary care providers in two ways within the electronic health record system (EHR): 1) a graphical summary of individual risk or 2) a line listing of all scheduled patients.

The investigators are introducing the risk-stratification tool in an urban safety-net primary care provider on a voluntary usage basis.

Inclusion Criteria:

• Encounters among patients seeking primary care service at any of the 9 Eskenazi Health FQHC clinics in Indianapolis, IN from January 2017 to May 2020.
• The propensity score matched primary care encounters from non-Eskenazi facilities.

Exclusion Criteria:

• Emergency encounters or hospitalizations