The Development, Implementation, and Evaluation of a Social Engagement Support System

In this protocol, we will develop and deploy a set of machine learning models that use multiple individual- and community-level data sources to predict which members use the emergency department to fulfill social or non-urgent needs as opposed to treatment for urgent medical conditions. These models will identify individuals whose social needs are driving inappropriate utilization so that high-risk individuals will be given enhanced outreach services to facilitate completion of a comprehensive social needs assessment. We will also develop and deploy an engagement support system that identifies and displays the characteristics of members that prevent them from engaging with a Community Based Organization (CBO). This system will use artificial intelligence techniques to identify characteristics of individuals who have historically disengaged from the social service pipeline before receiving social services and suggest potential strategies for increasing engagement.