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.