Considering social determinants when assessing risk

2 minute read

Considering social determinants when assessing risk

< 1 minute read

Peninsula Circle of Care developed a risk assessment tool that takes into account medical factors and key social determinants.

The Issue

When we first began the program we did a detailed review of many risk assessment tools. Some focused on a specific age group, others on a diagnosis, and others had a very high ceiling effect such that everyone fell into the high risk group. Very few of them included social determinants, which we realized through experience are very important in determining readmissions.


Mills Peninsula is a non-profit hospital in Burlingame, CA that has partnered with the Palo Alto Medical Foundation and Peninsula Family Services to develop the Peninsula Circle of Care program. The hospital has 241 beds and serves a primarily elderly population (average age of 81) living alone with 90% on Medicare. Peninsula Circle of Care, their transitions program, began in 2012 and is influenced by the Care Transitions Program and a community based model.

What We Tried

We worked with the Research Institute at the Palo Alto Medical Foundation to develop our own risk assessment tool. We started with some of the existing tools, but included social factors like what a patient’s living arrangement is like or their baseline functional status. At our weekly staff meetings, people shared client stories and we learned about causes of readmission to incorporate in our risk tool. We kept revising the risk tool based on its performance and feedback from our staff. The goal was something that would be pretty accurate, but still easy for the information to be extracted from our Electronic Health Record.


Our risk assessment tool has helped us focus on the right patients. It’s not perfect, but that’s why we still reach out for referrals from nurses, case managers, and doctors. We’re working on incorporating it into our EHR now so that patients will automatically get screened upon admission. We are also planning to complete an in depth research data validation of the tool.


No matter how good it is, your risk tool shouldn’t be the only deciding factor determining which patients to target. We depend on referrals a lot because there are some things that are just much easier to identify through observation rather than through a tool.

Organizational Background

Organization Name: Mills Peninsula Hospital

Location: 1501 Trousdale Drive, Burlingame, CA 94010, United States

Organization Type: Hospital