Annals of Family Medicine: EHR-Integrated Social Risk Tool Linked to Improvements in Blood Pressure Control in Primary Care Clinics
PROVIDENCE, R.I., March 18, 2026 /PRNewswire/ -- A cluster-randomized controlled trial published in Annals of Family Medicine reports that clinics using a clinical decision support tool to alert care teams to patients' social risks experienced greater improvements in blood pressure control over time and higher odds of social risk screening and documentation than clinics without the tool. There was no significant difference in blood sugar control between groups.
Social risks, such as food, housing and transportation insecurity, can complicate chronic disease management. While screening for social risks has expanded in recent years, less is known about how integrating that information into clinical workflows influences patient outcomes. The study was conducted in the OCHIN network. OCHIN is a national nonprofit consultancy committed to delivering knowledge-driven solutions for community health care organizations. Six clinics implemented the intervention, while 44 clinics served as controls and were followed for 12 months.
The intervention included electronic health record (EHR)-integrated alerts identifying patients overdue for social risk screening and decision-support prompts to care teams for adults with uncontrolled hypertension, uncontrolled diabetes, or visit no-show rates of 50% or higher. In some cases, the alerts appeared when clinicians ordered medications for eligible patients and prompted consideration of factors such as medication affordability, supply duration and adherence barriers. Other prompts supported communication with pharmacists and documentation of care adjustments related to social risks.
Blood pressure control over time improved in both groups. The odds of patients achieving good blood pressure control increased over time in intervention clinics compared with control clinics (odds ratio 1.09, 95% confidence interval 1.01 to 1.19). There was no statistically significant difference in patients achieving good blood sugar (Hemoglobin A1c) control between groups. Intervention clinics were significantly more likely to complete social risk screenings (odds ratio 7.3, 95% confidence interval 1.5 to 36.0) and document social risks using Z-codes (odds ratio 11.3, 95% confidence interval 3.1 to 40.7).
The findings from this trial suggest that integrating social risk information into clinical workflows may be associated with measurable improvements in patient outcomes, particularly hypertension control.
The research reported in this publication was supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under Award Number R01MD014886.
Article Cited:
Brenda M. McGrath, PhD; Rachel Gold, PhD, MPH; Jenna Donovan, MPH; Shelby L. Watkins, MPH; Arwen Bunce, MA; Maura Pisciotta, MS; Suzanne Morrissey, PhD; Mary Middendorf, BS; Hannah L. Fein, MS, MPH; Christina R. Sheppler, PhD; Anna C. Edelmann, MScN; Michael C. Leo, PhD; Danielle Hessler-Jones, PhD; and Laura M. Gottlieb, MD, MPH
Annals of Family Medicine is an open access, peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals of Family Medicine is sponsored by six family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, and the North American Primary Care Research Group. Annals of Family Medicine is published online six times each year, charges no fee for publication, and contains original research from the clinical, biomedical, social, and health services areas, as well as contributions on methodology and theory, selected reviews, essays, and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed for free on the journal's website, www.AnnFamMed.org.
SOURCE Annals of Family Medicine
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