Abstract: Healthcare providers are increasingly evaluated by the quality of care they deliver to their
patient panels and the extent to which their patients utilize external services such as the ED.
The predominant approaches for assessing quality of care delivered often do not account for
clinical comorbidities and rarely account for the individual social complexity of a patient. Social
and clinical complexity greatly influence a health system’s ability to deliver high-quality services
and affects a patient’s ability to comply with provider recommendations.

This proposal aims to: 1) engage with patients and clinicians to identify the most critical social
determinants of health to test in a model predicting healthcare utilization and engage health system
leaders to identify the quality of care measures of greatest interest; 2) assess whether clinic level
summaries of patients’ clinical comorbidity and SDH correlate with variability in clinic-level preventive
quality of care measures and rates of ED visits, avoidable hospitalizations, and other select primary
quality measures; and 3) engage stakeholders to identify how clinic level measures of comorbidity and
social complexity are useful to health system leaders, clinicians, and patients in managing population
health, resources, and decision-making, delivering quality clinical care, improving treatment adherence
and health. For this study, the coordinating site Accelerating Data Value Across a Network of Community
Health Centers (ADVANCE) will partner with the OneFlorida CDRN.