Abstract: Embodiments of a risk assessment system is disclosed, where the risk assessment system can receive patient related data (for example, patient records) and social determinants of health data to generate a risk model to predict potential health outcomes, such as, for example readmission risk, with accompanying social determinants of health insight, which may include actionable insights and deployed systems that follow interventions. The risk model can be used to calculate a risk score for a patient based on patient records and social determinants of health data associated with the patient to predict potential negative health outcome for the patient proactively so that actions can be taken using social determinants of health insights to prevent that outcome.

Abstract: Identifying and addressing an individual's socio-economic factors related to negative health outcomes for reducing the likelihood of negative health outcomes for the individual in the form of readmission rates, emergency department utilization, missed appointments/no-shows, etc., may be realized by employing aspects of the present disclosure. A social determinants of health (SDoH) system accesses and analyzes consumer marketing data associated with the individual, business data, and public transportation data held by various databases for identifying indicators of SDoH factors, determines an individual's propensity for SDoH factors, and determines an engagement strategy to address SDoH that impact the individual. The results may be included in a report or included in a user interface that is transmitted to the requestor. The results may be displayed in a way that enables the requestor to easily identify and act on the individual's SDoH using recommended engagement strategies.