AAPCHO Risk Stratification Collaboration

AIM Year 4 - CDC Workplan Deliverable

A6. Develop and test a strategy for making SDOH data actionable in clinical practice through a national standardized risk stratification model incorporating social risk data.

PM6. Risk Stratification Model

OM2. SDOH data capture with risk stratification to improve adult immunization priorities

Goal Statement (Pending Mutual Approval)

The central focus of this collaboration is to improve patient outcomes by identifying and addressing social and economic drivers of health and wellbeing (SEDOHW) at one CHC that uses PRAPARE and the pilot site that uses the newly devised risk stratification methodology.This is not a research endeavor. It does use scientific methods to collect evidence to support the development and creation, using informatics, of a system that will monitor utilization, actions taken, follow-up, and patient outcomes when SEDOHW are identify by the CHC. There is limited focus on what happens when a CHC patient reveals SEDOHW. Understanding the utility of PRAPARE and its additional risk stratification component is necessary to assess its impact at the CHC and patient level. Identifying barriers and facilitators to mitigate SEDOHW is required to drive systemic change. With this information, informatics can be used to develop a product that assists CHCs’ tracking of SEDOHW linkage and outcome. To accomplish this, we propose a mixed methods evidence development evaluation base on two CHC sites. One will be the site using the risk stratification methodology and the second site will be an established PRAPARE user. To better inform the informatics development, a two-site model is necessary to assess the difference between the one pilot site using the risk stratification components and a site that does not.