• Joshua R Vest, Nir Menachemi, Shaun J Grannis, Jennifer L Ferrell, Suranga N Kasthurirathne, Ying Zhang, Yan Tong, and Paul K Halverson.
• Department of Health Policy and Management, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana; Regenstrief Institute, Indianapolis, Indiana. Electronic address: joshvest@iu.edu.
• Am J Prev Med. 2019 Apr 1; 56 (4): e125-e133.

IntroductionSocial 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.MethodsAn 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.ResultsAmong 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.ConclusionsThis 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.Copyright © 2018 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

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