Identification of Patients for a Community Health Worker Program Using an Artificial Intelligence Algorithm

Community health workers (CHWs) help patients navigate community resources. CHW programs can improve health outcomes and reduce healthcare utilization, but identifying eligible patients is challenging. We developed an electronic health record (EHR)-based algorithm trained to predict referrals to a CHW program. Our objective was to evaluate whether an algorithm trained on historical referrals identifies a subgroup of patients that differs from the subgroup identified through questionnaire-based health-related social needs (HRSN) screening alone.

This analysis used data from Mayo Clinic primary care patients in Southeast Minnesota. We developed a gradient boosted time-to-event model that incorporated demographics, diagnoses, HRSN questionnaire responses, and HRSNs derived from clinical notes using natural language processing. We compared the characteristics of algorithm-identified patients with those identified through questionnaires and assessed the variable importance of model features.

The algorithm had AUC: 0.87 in the training and 0.92 in the hold out set. Patients flagged by the algorithm tended to use interpreter services more commonly (12.6% vs. 1.3%), have a non-English preferred language (14.1% vs. 2.3%), and have more instances of health literacy documented (5.36 vs. 1.29) compared to patients identified by the HRSN questionnaire. Only 47.0% of patients flagged by the algorithm had responded to the HRSN questionnaire within 2 years. Variable importance was highest for health literacy and financial strain from unstructured notes.

The algorithm is a chart-review prioritization tool for referral to the CHW program for patients that may overcome challenges to identifying patients with HRSNs, especially when questionnaire data is incomplete.