Automated system for risk determinantion, facilitation and community support to mitigate social determinants of health in minority populations

摘要 弱势群体和服务不足的人群，如少数民族和种族，穷人，LGBTQ社区 和那些有身体或智力残疾的人，往往遭受最大的健康风险，同时面临重大的 获得医疗保健的障碍。虽然生物学和临床风险会影响结果，但社会文化和 社会经济因素也造成了个人、社区和社区接受医疗保健服务的主要障碍。 和人口水平。这些健康的社会决定因素（SDOH），如交通， 识字率和财政状况可能严重限制参与为普通民众设计的保健方案。 糖尿病预防计划是一个很好的例子，生活方式的改变协议，被证明可以减少 2型糖尿病的风险降低了一半，因为糖尿病前期患者有减肥的风险。但尽管 该计划的有效性，超过50%的参与者在完成这一年的生活方式之前退出 改变计划，严重限制了计划的成功。这部分是因为像DPP这样的项目 很少考虑到本应帮助的得不到充分服务的弱势群体所面临的限制。 这种缺乏个人和社区层面的支持，加上医疗机构 在最需要的医疗设施之外，不设计用于支持患者健康，也不经济。 这就造成了现有系统无法克服的医疗服务差距。 Viora正在通过一个系统来缩小这种医疗服务差距，该系统将医疗保健系统、 服务不足的患者，以及未充分利用的社区资源和提供者，以促进更好的结果 像DPP这样的项目。通过使用基于SDOH因素的风险分层，每个DPP参与者都可以定制 考虑其社会经济和社会文化特点的干预措施。Viora卫生系统 通过患者、医疗服务提供者之间的简单沟通，将患者与当地资源联系起来， 社区服务，促进患者完成DPP计划，从而改善健康结果。在 第一阶段，Viora将在5000名少数民族和 服务不足的受试者选择最相关的变量进行风险评估和个人预防计划 发展系统将自动筛选符合条件、准备就绪且能够 坚持DPP，并将创建一个个性化的干预计划，这是最有效的降低他们的风险 但也是可行的。该系统的通信网络将扩大，以提供直接通信 在患者、DPP教练、健康提供者和社区资源之间，支持参与者 坚持自己的民进党目标。最后，该项目将评估系统的基本功能、偏好和 在一项人类受试者研究中，与服务不足的受试者和社区合作伙伴进行人类互动。 第一期工程完成后，便可证明我们的软件系统， VIORA系统，它将为第2阶段测试的最小可行产品的开发提供信息。

Abstract Vulnerable and underserved populations such as ethnic and racial minorities, the poor, the LGBTQ community and those with physical or intellectual disabilities, often suffer the greatest health risks while facing significant barriers to receiving healthcare. While biological and clinical risks influence outcomes, sociocultural and socioeconomic factors also create major barriers to receiving healthcare services, at an individual, community and population level for these populations. These social determinants of health (SDOH), such as transportation, literacy, and finances can severely limit participation in health programs designed for the general population. Diabetes Prevention Programs are a good example of a lifestyle change protocol that is proven to reduce the risk of type 2 diabetes by half for pre-diabetics patients at risk by encouraging weight-loss. But, despite the effectiveness of the program, more than 50% of participants drop out before completing this year-long lifestyle change program, severely limiting the program’s success. This is in part due to the fact that programs like DPP take little account of the limitations faced by underserved and vulnerable populations that it is meant to help. This lack of support at the individual and community level combined with the fact that healthcare institutions are not designed for, nor economical, in supporting patient health outside the medical facility where it is most needed. This creates a gap in healthcare service that current systems cannot overcome. Viora is closing this health services gap with a system that interfaces between the health care system, the underserved patient, and underutilized community-based resources and providers, to facilitate better outcomes in programs like DPP. By using risk stratification based on SDOH factors, each DPP participant can have tailored interventions that consider their socioeconomic and sociocultural characteristics. The Viora Health system connects patients to local resources using simple communication between the patient, health providers, and community services, facilitating patient completion of the DPP program, thereby improving health outcomes. In Phase I, Viora will evaluate a larger set of pre-diabetes and SDOH risk factors across 5000 minority and underserved subjects to select the most relevant variables for risk assessment and personal prevention plan development. The system will automatically screen pre-diabetic participants who are eligible, ready and able to adhere to DPP, and will create a personalized intervention plan that is the most impactful in reducing their risk but is also doable. The system’s communication network will be expanded to provide direct communication between the patient, DPP coach, health providers and community resources, to support the participant toward maintaining their DPP goals. Finally, the project will assess the basic function of the system, preferences and human interaction in a human subject study with underserved subjects and community-based partners. Completion of Phase I will demonstrate feasibility of our software system incorporating major components of the VIORA SYSTEM, which will inform the development of a minimum viable product to be tested in Phase 2.