Table 1 Data elements for analysis of social determinants and health outcomes

Race/Ethnicity, Age, Gender

Claritas/UNCC Metro Studies, Hospital Billing Data

6-12 months

Household Income

UNCC Metro Studies

12 months

Housing Density

UNCC Metro Studies

12 months

Distance to nearest grocery store

UNCC Metro Studies

12 months

Distance to Nearest Park/Green Space

UNCC Metro Studies

12 months

Sidewalk Access in Neighborhood

UNCC Metro Studies

12 months

Distance to Public Transportation

UNCC Metro Studies

12 months

Distance to Primary Care Clinic

UNCC Metro Studies

12 months

Living within a Primary Care Clinic Service Area

CHS Billing Data/Geographic Retrofitting Model [44]

12 months

Utilization of a Primary Care Clinic

CHS Billing Data

6 months

Percentage of Free Lunches in Neighborhood School

UNCC Metro Studies

12 months

Distance to Pollution Sources(Hazardous Materials, Coal Burning Plant)

UNCC Metro Studies

12 months

Number of Food Stamps Users in Neighborhood

UNCC Metro Studies, Dept. of Social Services

12 months

Social Network Analysis

Survey Data Collection

Ongoing

All Cause Hospitalizations in past year (yes/no)

CHS Hospital Billing Data

6 months

All Cause ED Visits in past year (yes/no)

CHS Hospital Billing Data

6 months

ED Visits for Primary

CHS Hospital Billing

6 months

Care Preventable or Treatable Illness in past year (yes/no)

Data/NYU Algorithm [62]

Utilization of a Primary Care Clinic in past year (yes/no)

CHS Hospital Billing Data

6 months

School Absenteeism Over 6 days (yes/no)

UNCC Metro Studies/CMS School Data

12 months

School Performance – passed EOG (yes/no)

UNCC Metro Studies/End of Grade Test Scores

12 months

Perceived Quality of Life & Health Status (Aim 3,Validation)

Survey and Qualitative Data Collection

Ongoing