Impact of Social Risk Decision Support

Study Overview
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Brief Summary
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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
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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.

Official Title
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Improving Population and Clinical Health With Integrated Services and Advanced Analytics

Conditions
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Health Social Determinant

Intervention / Treatment
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* Other: Risk screening tool exposure


Participation Criteria
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Eligibility Criteria
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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
Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Screening
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Multiple observation, pre-post with a secondary data source comparison group design, and a difference-in-difference modeling approach.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Intervention group<br>Encounters at primary care clinics with the risk screening tool | Other: Risk screening tool exposure<br>* Risk screening tool is available to providers<br>|
| No Intervention: Comparison group<br>Propensity score matched comparison encounters | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| ED utilization rate | Rate of potentially avoidable emergency department utilization as determined by encounters recorded in health information exchange data and categorized using the NYU ED Algorithm. | 6 months | 
| Missed primary care appointments rate | Rate of no show / cancelled appointments at the intervention site primary care clinics as recorded in the intervention site's electronic health record system | 6 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Hospitalization rate | 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 | 6 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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risk prediction