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

This study will leverage the rich electronic data sources within Kaiser Permanente to create pragmatic tools for improving health and equity among primary care patients with the highest medical and social needs. Aim 1: Use advanced analytic methods to predict actionable nonmedical barriers to care experienced by patients with multiple chronic conditions; Aim 2: Implement a dashboard linked to the electronic health record that will enable care providers to sort and manage registries of patients with multiple chronic conditions; and Aim 3: Pilot the use and implementation of this dashboard tool in 3 geographically distinct, high-need communities served by three Kaiser Permanente regions (Northern California, Washington, Colorado).

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