CP37 - Incorporating Social Determinants of Health Data into Risk Stratification Models to Address Health Inequities: The PRAPARE Stakeholder-Vetted Risk Stratification Model

Poster Type: Research

Category: Social Determinants of Health

Research Objectives: Risk stratification is the process of identifying and predicting patients that are at high risk and prioritizing the management of their care in order to improve their health. We proposed a new risk stratification model that includes PRAPARE social determinants of health (SDH) to assess patients’ health more comprehensively.

Study Design/Methods: We hosted a PRAPARE Risk Stratification Learning Collaborative (LC), consisting of nine community health center stakeholders, with representatives from eight states, to leverage the experiences of the stakeholders to develop an improved and stakeholder-vetted national standardized PRAPARE Risk Stratification Model with options for localized methodologies and discuss how it can be incorporated into practice to improve population health. During the process, we also worked with the LC teams to conduct two brief Plan, Do, Study, Act (PDSA) evaluations of the PRAPARE Risk Stratification Model.

Principal Findings and Quantitative/Qualitative Results: The final PRAPARE Risk Stratification Model included four components: SDH, Clinical, Mental Health/Substance Abuse (MH/SA), and Utilization. The SDH Component included the SDH factors in the PRAPARE assessment categorized into seven clusters. The Clinical Component included all cancer categories, cardiovascular disease, chronic lower respiratory disease, diabetes, chronic liver disease, HIV, Tuberculosis, and Obesity. The MH/SA Component included conditions of depression and other mood disorders, anxiety disorders, attention deficit and disruptive behavior disorders, other mental disorders, alcohol-related disorders, tobacco use disorder, and other substance-related disorders. The Utilization Component included both Emergency Department (ED) visits and inpatient hospital stays.

Conclusions on Impact on Health Centers: Based on quantitative and qualitative results, all components with the exception of SDH were assigned a weight of 20%. To highlight the critical impact of SDH on patient health, the SDH Component was assigned a weight of 40%. In this collaborative process, we uplifted the community voices that best understand the needs of their underserved patients and, in doing so, we strove to create a system that accurately reflects the needs of this underserved community. We are planning a larger multi-state collaborative to evaluate the validity, clinical utility, and impact of the SDH risk stratification model with patient-level data.

Author(s):

Vivian Li, MS, Research Project Manager and Analyst, AAPCHO

Rosy Chang Weir, PhD, Director of Research, AAPCHO