Health Social Determinant
Conditions
Keywords
risk prediction
Brief summary
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).
Detailed description
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.
Interventions
OTHERRisk screening tool exposure
Risk screening tool is available to providers
Sponsors
Robert Wood Johnson Foundation
Indiana University
Study design
Allocation
NON_RANDOMIZED
Intervention model
PARALLEL
Primary purpose
SCREENING
Masking
NONE
Intervention model description
Multiple observation, pre-post with a secondary data source comparison group design, and a difference-in-difference modeling approach.
Eligibility
Sex/Gender
ALL
Healthy volunteers
Yes
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
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| ED utilization rate | 6 months | Rate of potentially avoidable emergency department utilization as determined by encounters recorded in health information exchange data and categorized using the NYU ED Algorithm. |
| Missed primary care appointments rate | 6 months | Rate of no show / cancelled appointments at the intervention site primary care clinics as recorded in the intervention site's electronic health record system |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Hospitalization rate | 6 months | Rate of all cause and potentially preventable hospitalization as determined by encounters recorded in health information exchange data and categorized using AHRQ's prevention quality indicator definitions |
Countries
United States
Outcome results
None listed