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Impact of Risk Stratification on Referrals and Uptake of Wraparound Services That Address Social Determinants: A Stepped Wedged Trial.

Abstract：

INTRODUCTION:Social determinants of health are critical drivers of health status and cost, but are infrequently screened or addressed in primary care settings. Systematic approaches to identifying individuals with unmet social determinants needs could better support practice workflows and linkages of patients to services. A pilot study examined the effect of a risk-stratification tool on referrals to services that address social determinants in an urban safety-net population. METHODS:An intervention that risk stratified patients according to the need for wraparound was evaluated in a stepped wedge design (i.e., phased implementation at the clinic level during 2017). Staff at nine federally qualified health centers received a daily report predicting patients' needs for social worker, dietitian, behavioral health, and other wraparound services (categorized as low, rising, or high risk). Outcomes included referrals and uptake of appointments to wraparound services. RESULTS:Among 238,087 encounters, providing clinic staff with risk-stratification scores increased the odds that a patient would be referred to a social worker. For patients categorized as high risk, the odds of a social work referral was 65% higher than controls and similar patients, but lower effect sizes were observed for individuals categorized with rising and low risk. Among referred patients, the intervention was generally associated with increased odds of kept appointments. CONCLUSIONS:This study provided preliminary evidence that risk-stratification interventions to identify patients in need of wraparound services to address social determinants can increase referrals and uptake of services that may address social drivers of disease burden.

journal_name

Am J Prev Med

journal_title

American journal of preventive medicine

authors

Vest JR,Menachemi N,Grannis SJ,Ferrell JL,Kasthurirathne SN,Zhang Y,Tong Y,Halverson PK

doi

10.1016/j.amepre.2018.11.009

subject

Has Abstract

pub_date

2019-04-01 00:00:00

pages

e125-e133

issue

4

eissn

0749-3797

issn

1873-2607

pii

S0749-3797(18)32433-4

journal_volume

56

pub_type

临床试验,杂志文章

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