Moving Upstream: Three Regions’ Approaches for Addressing Social Determinants and Needs to Improve Health Outcomes

Abstracts from the Kaiser Permanente2018 National Quality Conference


Nicole Friedman, MS; Irene Alvarez-Zamzow, MPH; Adam Sharp, MD, MS; Ranu Pandey, MHA

From Colorado, Georgia, Mid-Atlantic States, Northern California, Northwest, Southern California, Program Offices

Background: Social and economic circumstances are known to have a powerful impact on health outcomes and health care use. Addressing these circumstances is crucial for improving health equity and fulfilling the Triple Aim. There is growing recognition of the importance of health care organizations assessing and addressing these issues in collaboration with community organizations. The 2014 Institute of Medicine report recommended inclusion of social and behavioral domains in electronic health records, and several Kaiser Permanente (KP) programs wanted to incorporate social needs assessment (SNA) into their health assessments and protocols.
Methods: Population: SNA programs servicing 3 target populations: KP Southern California (KPSC) Health Leads (HL) predicted high users (top 1%); KP Northern California (KPNC) Medicaid Managed Care (MMC) members; KP Northwest (KPNW) navigator program handling referrals from across the care continuum. Intervention: Social needs screening by various modes (phone, in-person, using a validated SNA questionnaire. Members with identified needs referred or connected with appropriate KP or community resources. Outcome measures: Phase 1: Number of members screened; social needs prevalence; count and percentage of members identifying one or more needs. For KPSC HL pilot, utilization and costs for intervention and comparison groups. Phase 2: successful referrals, health outcomes, and utilization impact.
Results: KPNW Navigator Program: 10,000 patients screened. More than 42,000 social v-codes in the medical record and more than 12,000 community resource referrals. Additionally, 20% of these referrals were either fully or partially satisfied. KPSC HL pilot (case control): High prevalence of social needs for top 1%; large voltage drops in communication from screen to connection; telephone intervention appears similar, may be more efficient; no overall short-term impact on costs and/or utilization except for very-low-income members (Medicaid, Dual Eligibles). KPNC MMC program: KP SNA tool (YCLS or Your Current Life Situation) integrated into onboarding assessment tool which will be used for all KPNC MMC members in 2018.
Discussion: KP has made great progress in member SNA. The Care Management Institute, with regional partners, developed an SNA questionnaire and item bank that all programs are being encouraged to use to enable cross-program comparisons and pooling of SNA data. SNA tools are integrated into KP HealthConnect. Most KP Regions have or are planning targeted SNA programs, and the Care Management Institute is facilitating sharing of learnings and best practices across programs/Regions. Questions remain about highest priority populations for SNA, staffing requirements, assessment/referral protocols, documentation and tracking of referrals, how to address needs (eg, referral vs active linkage), and how to identify and work with community resources.

etoc emailClick here to join the E-TOC list or text TPJ to 22828. You will receive an Email notice with the Table of Contents of each issue.


The Kaiser Permanente National CME Program designates this journal-based CME activity for 4 AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.


27,000 print readers per quarter, 15,350 eTOC readers, and in 2018, 2 million page views of TPJ articles in PubMed from a broad international readership.

The Permanente Press

The Permanente Press publishes The Permanente Journal and books related to healthcare. For information about subscriptions, missing issues, billing, subscription renewal, and back issues, Email:

ISSN 1552-5775 Copyright © 2019

All Rights Reserved.