Care System Analytics to Support Primary Care Patients with Complex Medical and Social Needs

项目概要/摘要 三分之一的美国人患有多种慢性病（MCC），其中80%的人年龄在65岁或以上。 由于社会原因，这些人中的许多人没有体验到循证医学的全部益处。 这些障碍导致健康不平等和健康结果较差。这些 潜在的可采取行动的障碍没有系统地纳入现有的初级保健模式， 在初级保健环境中认识不足和管理不足。需要研究开发工具， 可以系统地和反复地识别具有可操作的社会障碍的患者，并将他们与主要的 护理团队成员最适合解决和克服这些障碍。在这一建议中，我们寻求解决 通过使用先进的分析技术来预测高风险患者， 社会决定的护理障碍（目标1），建立MCC社会需求EHR链接仪表板， 初级保健团队反复优先考虑和管理患有MCC的成年人， 确定的健康障碍（目标2），并在3个低- 收入社区（里士满，加利福尼亚州;雷尼尔谷，华盛顿州;和奥罗拉，CO）由3个不同的凯撒服务 常设组织（目标3）。我们的团队结构旨在支持我们之间的强大协作， 医疗系统内的科学研究人员团队和利益相关者合作伙伴，包括临床 和运营卫生系统领导人，社区领导人，初级保健团队提供者和患者 和他们的照顾者。我们将使用透明的先进分析方法，以用户为中心的设计方法， 和强大的实施评估实践，以确保我们的仪表板工具可以有效地适应 并复制到不同的临床环境中，我们的结果可以指导后续的实施决策。

Project Summary/Abstract One third of Americans have multiple chronic conditions (MCC), including 80% of individuals age 65 or older. Many of these individuals do not experience the full benefit of evidence-based medicine due to socially determined barriers to effective care that contribute to health inequity and poorer health outcomes. These potentially actionable barriers are not systematically incorporated into existing primary care models and may be underrecognized and undermanaged in the primary care setting. Research is needed to develop tools that can systematically and iteratively identify patients with actionable social barriers and link them to the primary care team members best suited to address and overcome these barriers. In this proposal, we seek to address current gaps in knowledge by using advanced analytic techniques to predict patients at high risk for having socially-determined care barriers (Aim 1), building an MCC Social Needs EHR-linked dashboard to enable primary care teams to iteratively prioritize and manage adults with MCC complicated by actionable, socially determined barriers to health (Aim 2), and evaluating the acceptability and use of this dashboard in 3 low- income communities (Richmond, CA; Rainier Valley, WA; and Aurora, CO) served by 3 different Kaiser Permanente organizations (Aim 3). Our team structure is designed to support robust collaboration between our team of scientific researchers embedded within health systems and stakeholder partners that include clinical and operational health system leaders, community-based leaders, primary care team providers, and patients and their caregivers. We will use transparent advanced analytic approaches, user centered design methods, and robust implementation evaluation practices to ensure that our dashboard tool can be effectively adapted and replicated to different clinical contexts and our results can guide subsequent implementation decisions.