The Best Year of Angela’s Life


Kumara Raja Sundar, MD

Perm J 2018;22:18-076 [Full Citation]
E-pub: 10/01/2018


Using a patient story, this narrative demonstrates why health care organizations, specifically primary care clinics, should strive to identify and to address social needs. This story demonstrates how Kaiser Permanente Washington, by using community resource specialists, has empowered primary care clinics to address social needs in a health care setting to improve patient care and experience.


Angela (name has been changed), in her late 50s, had achieved some stability in her life after a painful childhood and a tumultuous adulthood. She had secured subsidized senior housing because of a severe mental health disability requiring weekly electroconvulsive therapy. As a family medicine physician at Kaiser Permanente Washington (KPWA), I witnessed the value of a community resource specialist in my clinical practice, but I longed for patients to share their stories. Angela volunteered. Her eagerness to share her story with me was tempered only by her occasional memory lapses. Pushing aside the 1000-piece puzzle on her table, she asked me to sit while she explained how Larnette, the community resource specialist at her primary care clinic, had provided her with the support, motivation, and hope to improve her health by addressing her social needs.

During Angela’s first visit with her new primary care physician, Dr Bryce, she mentioned that she wanted to find more ways to exercise in the community but didn’t know where to start. After addressing her chronic conditions and ensuring her preventive care needs were met, Dr Bryce referred Angela to Larnette. Dr Bryce did not have knowledge about all the resources available in the community to help Angela start exercising; nor did she feel like she had adequate time in her 20-minute clinic visit to identify and prescribe her the right community resources.

Community Resource Specialist

The community resource specialist at KPWA has many roles in the primary care clinic, but for the patient, the goal is twofold: To connect patients with resources—inside and outside KPWA—and to provide a level of supportive health coaching that primary care practitioners lack time for during quick office visits. Larnette, as the community resource specialist in Dr Bryce’s clinic, typically connects to patients through a warm handoff. A warm handoff in clinic is when one member of the care delivery team introduces Larnette, as a fellow team member, to the patient in real-time and explains the role of the community resource specialist in addressing the patient’s needs.

After connecting to Angela, Larnette was able to identify challenges facing Angela through 10 encounters during the following 3 months. During this time, she connected Angela with several resources and coached her on how to receive the care she deserves.

Because Dr Bryce had specifically referred Angela for group exercise opportunities, Larnette, in her first conversation with Angela, shared with her the “Walk and Talk” program—a free weekly event where health care teams walk for 30 to 45 minutes with community members in accessible community settings. During her assessment, however, she also learned that Angela had limited access to adequate food and received food from a local food bank. Larnette realized that she would qualify for a program called Fresh Bucks because of her food insecurity—a term that signifies Angela had inadequate food for healthy living owing to a lack of money.1

Fresh Bucks is a program that provides vouchers matching the value of recipients’ weekly food stamp allotments for use at farmers markets in King County, WA. In King County, about 12% of households are food insecure, matching the national statistic.2,3 Angela fell within that percentage. Fresh Bucks is one solution to address the problem of food insecurity and poor access to healthful foods in King County. The program is a success by many measures. As of 2016, it had 4556 participating residents and 14,743 shopper visits and contributed $591,786 to the local economy.4 Although she qualified for this program, Angela did not even know it existed.

Larnette explained to Angela how the program works and how to apply for it. After her conversation with Larnette, Angela was curious to see if anybody else she knew had knowledge about the program. She asked her neighbors and friends at the senior housing complex about Fresh Bucks, but she was met with blank stares. She even asked the housing resident services manager, but that person had not heard about the program either. No one she knew had heard about Fresh Bucks.

Accessing Community Resources

In the US—because of a myriad of cultural, economic, and political factors—the ratio of spending on social services to health care is 1:1 compared with 2:1 in many peer countries in the Organization for Economic Co-operation and Development.5 This has hamstrung the social services sector from adequately addressing social needs. King County is better off than many other counties in the nation. There was a program already available and accessible to help address food insecurity. Angela was just unaware the program existed.

Creation of more robust communication outlets by the social services sector would ensure people like Angela were aware of community resources and had the necessary support to access those resources. Unfortunately, the current system was not meeting Angela’s needs. The community resource specialist was one way for our organization and our clinic to bridge this gap by understanding the resources available in our community and ensuring our patients were connected with these resources, especially if we were their sole means to improve their health.

Now, Angela receives $40 every 2 weeks through Fresh Bucks and goes to the farmers market every Saturday. “I get fresh fruits and vegetables. My favorite dish now is spaghetti squash with mushroom, onions, zucchini, and tomatoes.” She added, “Before, I didn’t get any vegetables or fruits. It was just too expensive. The best part is that I get to go to the farmers market and get out on the weekends.” She repeated, “Seeing other people. That’s the best part.” By building better connections with her community, Angela felt she had decreased her social isolation, a known predictor of increased mortality.6 Through Larnette, we had improved Angela’s health by not only addressing her food insecurity but also helping her form stronger connections with her community.

Addressing Social Needs in the Primary Care Clinic

Health care organizations have created various models to identify and address social needs. Some have created call centers to conduct telephonic outreach to patients.7,8 Others have staffed Emergency Departments with community health workers.9 Our approach has been to place the community resource specialist in the primary care clinic. Over time, the community resource specialist has become a vital and irreplaceable member of the primary care team.

When I asked Dr Bryce about what she would have done in Angela’s case if there was no community resource specialist, she paused. “I’m not sure. I don’t know. I would have probably said, ‘I’ll look into it’ because I couldn’t have done anything at that visit. I would’ve tried to find something at the end of the day.” However, Dr Bryce had an infant waiting for her at home. Adding more work to the end of the day did not seem to be the best answer. She reflected on several patients who presented to her in acute crisis with social needs. She emphasized that she could not have provided appropriate medical care to them if Larnette had not helped address the patients’ social needs first. She continued, “We just need the support. I think addressing social needs is a core aspect of being an effective healer.” She had no doubt that a primary care clinic should address patients’ unmet social needs, particularly if their existing support network had failed to meet those needs.

Angela didn’t hesitate to answer the question about where social needs should be addressed. “The clinic. It’s convenient, it’s where I would go first, and it’s where I already go for my appointments. And the doctor knows me and what I’m going through,” she replied.

For Angela, it was also about trust. Angela recounted a clinic visit decades ago when her son was a year old. She tried to tell the doctor about not having enough food, following a particularly painful night where she had only one can of green beans for both her and her infant. She recalled tearfully, “It just felt like they didn’t care. I could tell when I looked at the doctor. It was like they didn’t have time for what I was going through. They just wanted to talk about my medical problems.” That day, she stated, she lost trust in her physician and her clinic. Soon after, she stopped going to the clinic regularly.

It was clear that Angela and Dr Bryce treasured having Larnette at their primary care clinic. Although social needs can be, and should be, addressed in a variety of settings to ensure that every person accesses the resources needed to thrive, Angela’s case demonstrates that primary care clinics must identify and address social needs. A primary care clinic’s ability to address acute, chronic, and preventive care is affected by social needs, often negatively if unidentified and unaddressed. Addressing social needs does not divert resources from a clinic’s core responsibilities or diminish its quality of care; it bolsters them.

Advocacy and Negotiation

After helping address her food insecurity, Larnette continued to help Angela in several other ways. She helped Angela navigate a complex health care system to get the right care from the right person at the right time. Dr Bryce had advised her that she needed a walker because of her gait instability and referred her to a gastroenterologist for an ongoing medical problem, but Angela was already seeing 4 other specialists and had trouble coordinating her care. She was lost and didn’t know who could help. Even in an integrated health system, care can be difficult to obtain. Larnette made a 3-way phone call with Angela and the durable medical equipment company to get her the walker. Then, she made a 3-way phone call with the gastroenterology team to elaborate on Angela’s history and schedule the appropriate procedure for her.

Angela didn’t see it as merely navigating the system. “Larnette advocates for me when I feel like I can’t. It’s hard. I have trouble negotiating to get what I want.” For Angela, it was Larnette’s advocacy and ability to negotiate that she valued the most. Negotiating is an important skill for a patient in a complex, multilayered health care system. Patients must be able to state what they want and need and compare it with what each staff member has to offer. By always making 3-way calls, Larnette advocated for Angela, helped her navigate KPWA, and taught her how to seek and receive the care she needs and deserves.

Angela ended the conversation with me by saying, “Sixty is going to be the best year of my life.” I was amazed at the bold statement and wanted clarification. I asked with curiosity, “Why is that?” She replied confidently, “I just know it. I’m finally getting the right treatment for my mood. I’m eating better. Larnette also connected me to a Walk and Talk program. I haven’t had a chance to go yet. But I’m going to try to. Sixty is going to be the best year of my life.”

As a team, we are providing more than health care. We are giving Angela—and other patients like her—hope by addressing all their needs, including social needs. We are realizing our mission of helping our patients achieve better health.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.


Kathleen Louden, ELS, of Louden Health Communications provided editorial assistance.

How to Cite this Article

Sundar KR. The best year of Angela’s life. Perm J 2018:22:18-076. DOI:

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Keywords: community health workers, food supply, patient experience, primary health care, social determinants of health


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