Impact of Social Risk Decision Support

Improving Population and Clinical Health With Integrated Services and Advanced Analytics

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