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

> **NIH AHRQ R18** · KAISER FOUNDATION RESEARCH INSTITUTE · 2021 · $629,284

## Abstract

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.

## Key facts

- **NIH application ID:** 10259671
- **Project number:** 5R18HS027343-03
- **Recipient organization:** KAISER FOUNDATION RESEARCH INSTITUTE
- **Principal Investigator:** RICHARD W GRANT
- **Activity code:** R18 (R01, R21, SBIR, etc.)
- **Funding institute:** AHRQ
- **Fiscal year:** 2021
- **Award amount:** $629,284
- **Award type:** 5
- **Project period:** 2019-09-30 → 2023-09-29

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10259671

## Citation

> US National Institutes of Health, RePORTER application 10259671, Care System Analytics to Support Primary Care Patients with Complex Medical and Social Needs (5R18HS027343-03). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/10259671. Licensed CC0.

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