Addressing Social Needs: Organizational Learnings and Connecting with Our Communities


Sarita A Mohanty, MD, MPH, MBA; John F Steiner, MD, MPH;
Nicole Friedman, MS; Briar Ertz-Berger, MD, MPH

Abstracts from the Kaiser Permanente 2019 National Quality Conference

From Colorado, Georgia, Hawaii, Mid-Atlantic States, Northern California, Northwest, Southern California, Washington, Program Office

Background: Social determinants of health account for 40% of health outcomes. Within Kaiser Permanente (KP), 30% of members live below 250% of the federal poverty level. KP lacks a systematic approach to assess social needs, to refer members to resources, to confirm that needs have been met, and to collaborate with community-based organizations (CBOs). The Social Needs Network for Evaluation and Translation (SONNET) promotes shared learning by helping design projects that employ effective measures, incorporate successful staffing and information-technology solutions, and evaluate outcomes rigorously to inform leadership decisions.
Methods: Social interventions have proliferated across KP, but outcomes are rarely evaluated. SONNET gathered information about program goals, design, measures, and outcomes and compiled this information into an online inventory, using a “care-continuum” model to report the findings in an online scoping review. These findings influenced key features of the Social Services Resource Locator (SSRL), including identification of member needs, submission and tracking of referrals to CBOs, reporting and analytics, and development of community partner networks. Staff, practitioners, members, and caregivers will have access to this tool and will work closely with community networks. The SSRL will provide extensive data to deepen the understanding of the effectiveness of social interventions.
Results: SONNET identified 35 KP programs, most of which included patients with complex needs or high costs. Food insecurity (8%-38%), housing instability (3%-11%), energy/utility needs (7%-24%), transportation barriers (16%-34%), and medical cost concerns (8%-37%) were common. Of members, 13% to 45% with basic needs were referred to community organizations, and 12% to 23% indicated that basic resource needs were met. One program found 7% to 12% reductions in utilization for members with predicted high costs. SSRL predeployment activities have included design sessions, review of vendor tools, and assessment of and planning with deployment sites. Evaluation in early deployment sites will include characteristics of members, description of needs and community resources, referral counts, and communication with CBOs. Qualitative assessment will describe the experience of staff and clinicians, members, and community partners.
Discussion: KP has accumulated substantial organizational knowledge in program planning and implementation, but significant gaps remain in outcome assessment. The SSRL provides an opportunity to fill these knowledge gaps, and particularly to assess the health outcomes of social interventions. Anticipated benefits of the SSRL program include improved health outcomes; staff and practitioner satisfaction; and confidence in addressing total health, member satisfaction, and alignment with new federal and state regulatory requirements. The SSRL enables KP to be a leader in health care delivery by understanding and supporting the social needs of its members, while promoting system transformation and community-level capacity development and partnership-building.

Abstracts from the Kaiser Permanente 2019 National Quality Conference


Click here to join the eTOC list or text ETOC to 22828. You will receive an email notice with the Table of Contents of The Permanente Journal.


2 million page views of TPJ articles in PubMed from a broad international readership.


Indexed in MEDLINE, PubMed Central, EMBASE, EBSCO Academic Search Complete, and CrossRef.




ISSN 1552-5775 Copyright © 2021

All Rights Reserved