Co-designing an Outpatient Clinical Decision Support Prototype for Managing Social Risks in Patients Living with...

Area of Science:

• Gerontology
• Health Informatics
• Social Determinants of Health

Background:

• Patients living with dementia (PLWD) require attention to social determinants of health (SDoH).
• Social information is often unavailable or incomplete during care encounters.
• Clinicians lack certainty on how to act on social risk information for PLWD.

Purpose of the Study:

• Co-design the Intelligent Social Risk Management in Alzheimer's Disease and Alzheimer's Disease-Related Dementias Patients (iSMART) clinical decision support (CDS) prototype.
• Integrate an AI-driven individualized polysocial risk score (iPsRS) to identify PLWD at high risk for hospitalization.
• Improve social risk management in dementia care.

Main Methods:

• Qualitative user-centered design study with nine outpatient providers and clinical staff.
• Semi-structured interviews to explore perceived social risks and gather feedback on the iSMART prototype.
• Rapid qualitative and thematic analysis of interview transcripts.

Main Results:

• Lack of caregiver support, financial strain, and transportation issues identified as key social factors.
• iSMART prototype seen as helpful for identifying social risks, prioritizing hospitalization factors, and connecting patients to resources.
• Suggested improvements include auto-populated SDoH fields, caregiver presence input, and clearer risk visualizations.

Conclusions:

• Outpatient providers and staff view the iSMART prototype as a promising tool for social risk screening and resource connection in dementia care.
• Findings inform practical strategies for integrating iPsRS-informed CDS tools into dementia care workflows.
• The iSMART tool supports social risk management for PLWD.