Abstract: What is disclosed is a computerized system and method that include a data ingestion logic module that automatically receive, cleanse, and process data associated with a plurality of patients to create a plurality of holistic patient records that include identity and demographic metrics associated with each patient, clinical metrics associated with each patient, clinical utilization metrics associated with each patient, social determinants of health metrics associated with each patient at the blockgroup level, and social determinants of health metrics associated with each patient at the census track level.