Volume 22 Supplement - Addressing Basic Resource Needs in Health Care Settings: From Clinic to Community



Food Insecurity—Addressing Basic Resource Needs in Health Care Settings
John F Steiner, MD, MPH

Original Research and Contributions

Evaluation of the Learning to Integrate Neighborhoods and Clinical Care Project: Findings from Implementing a New Lay Role into Primary Care Teams to Address Social Determinants of Health
Clarissa Hsu, PhD; Erin Hertel, MPA; Eric Johnson, MS; Carol Cahill, MLS; Paula Lozano, MD, MPH; Tyler R Ross, MA; Kelly Ehrlich, MS; Katie Coleman, MSPH; June BlueSpruce, MPH; Allen Cheadle, PhD; Juno Matthys; Michelle Chapdelaine, MPH; Marlaine Gray, PhD; Janice Tufte; Michele Robbins
The authors analyzed data from staff interviews, patient focus groups, clinic site visits, patient surveys, the electronic health record, and administrative sources. Primary care teams reported workload easing. Patients who used community resource specialists (CRSs) and participated in focus groups reported behavior changes and improved health, although no changes were detected from electronic health records or patient survey data. Key learnings include the need to clearly define the CRS role, ensure high visibility to clinical staff, and facilitate personal introductions of patients
(warm handoffs).

Perceptions and Experience of Patients, Staff, and Clinicians with Social Needs Assessment
Courtnee Hamity, PhD; Ana Jackson, PhD; Lunarosa Peralta, MPH; Jim Bellows, PhD
Qualitative and descriptive analysis of data from member and clinician focus groups, interviews, and surveys among 68 members and family caregivers who had participated in social needs assessment programs and 90 clinicians and staff in the Kaiser Permanente Colorado, Georgia, Northern California, Northwest, and Southern California Regions. Careful attention to communications is required because members may be uncertain or concerned about the purpose of the assessment and the dissemination of sensitive information. Messaging should assure members about data use and dissemination and what they can expect after screening.

Professional Medical Association Policy Statements on Social Health Assessments and Interventions
Geoff Gusoff, MD; Caroline Fichtenberg, PhD; Laura M Gottlieb, MD, MPH
Among the 42 professional medical associations included in this study, 9 (21%) published 39 relevant statements. Fourteen of these statements referred to clinic-based social or economic health-screening activities, 34 referred to clinical interventions to promote social or economic health, and 3 referred to strategies for financial support for these activities. Thirty-six of the 39 statements (92%) were published after 2008.

Using Neighborhood-Level Census Data to Predict Diabetes Progression in Patients with Laboratory-Defined Prediabetes
Julie A Schmittdiel, PhD; Wendy T Dyer, MS; Cassondra J Marshall, DrPH, MPH; Roberta Bivins, PhD
Retrospective cohort study of all 157,752 patients aged 18 years or older from Kaiser Permanente Northern California with laboratory-defined prediabetes. Patients were more likely to progress to diabetes if they lived in an area where less than 16% of adults had obtained a bachelor’s degree or higher, where median annual income was below $79,999, or where Supplemental Nutrition Assistance Program benefits were received by 10% or more of households.

Universal Screening for Social Needs in a Primary Care Clinic: A Quality Improvement Approach Using the Your Current Life Situation Survey
Kumara Raja Sundar, MD
Kaiser Permanente’s Care Management Institute created a screening tool, Your Current Life Situation, to identify social needs for populations at risk of high health care utilization. In a rapid stakeholder analysis, concerns were the tool’s length and low screening acceptability and the possibility that too few or too many patients may have social needs. Of 125 office visits and 111 patients screened, 27% had positive findings and requested help. Of the 14 patients not screened, only 1 opted out of screening. Practitioners and medical assistants stated that the tool did not disrupt clinic work flow.

Measuring Patients’ Basic Resource Needs: The Role of a Small Survey to Guide Operational Decisions
John F Steiner, MD, MPH; Tina K Kimpo; Christopher I Lawton; Andrew T Sterrett, PhD;Andrea R Paolino, MA; Chan Zeng, PhD
A well-validated, 2-item food-insecurity measure had fewer false-positive responses than a previously used single-item measure. Individuals with food insecurity commonly reported concurrent difficulties paying for housing, transportation, and utilities, and cost-related medication nonadherence. These basic resource needs persisted during a 3-month period. Of the 110 older adult members surveyed from Kaiser Permanente Colorado, 47.4% had delayed paying for food to pay for housing, and 22.0% had delayed paying for housing to pay for food.


Health Care Steps Up to Social Determinants of Health: Current Context
Loel S Solomon, PhD, MPP; Michael H Kanter, MD
As the articles in this Supplement demonstrate, the social determinants of health are a major focus for Kaiser Permanente and the broader US health care system. The question is now what the role is for the US health care system in creating the right policy context for innovation and how health care can partner more effectively with providers of social services to meet patients’ most pressing needs given the fragmented, typically underresourced nature of the social sector.

Interventions to Address Basic Resource Needs in Kaiser Permanente: A Care Continuum and an Outcomes Wheel
John F Steiner, MD, MPH; Jim Bellows, PhD; Matthew P Banegas, PhD, MPH; Laura M Gottlieb, MD, MPH
This framework combines a care continuum with an outcomes wheel with 5 steps: 1) plan new interventions to generate evidence of effectiveness, 2) assess basic resource needs in broad or targeted membership groups, 3) connect individuals to community organizations that can fulfill basic resource needs, 4) improve health outcomes through these interventions, and 5) spread effective programs to other settings. Each step has multiple subcomponents that support implementation and evaluation. The outcomes wheel identifies health outcomes at the individual, clinical, social, and system levels that can address these different priorities.

Uses and Misuses of Patient- and Neighborhood-level Social Determinants of Health Data
Laura M Gottlieb, MD, MPH; Damon E Francis, MD; Andrew F Beck, MD
Some screening tools rely on patient- or household-level screening data collected from patients during medical encounters. Others rely on data available at the neighborhood-level that can be used to characterize the environment in which patients live or to approximate patients’ social or economic risks. Four case examples were selected from different health care organizations to illustrate strengths and limitations of using patient- or neighborhood-level social and economic needs data to inform a range of interventions. This work can help to inform health care investments in this rapidly evolving area.

Toward Addressing Social Determinants of Health: A Health Care System Strategy
Nicole L Friedman, MS; Matthew P Banegas, PhD, MPH, MS
Kaiser Permanente Northwest (KPNW), an integrated health care delivery system, implemented a comprehensive approach for patients’ Social Determinants of Health (SDH). Tools included use of electronic health record-based data elements, International Classification of Diseases, Tenth Revision social diagnostic codes (Z codes), and the development of novel work flows via nonclinical patient navigators to address patients’ SDH through community resource referrals. From March 2016 to March 2018, KPNW patient navigators screened 11,273 patients with SDH identifying and documenting 47,911 SDH in the electronic health record, and 18,284 community resource referrals were made for 7494 patients.

Lessons Learned from Implementation of the Food Insecurity Screening and Referral Program at Kaiser Permanente Colorado
Sandra Hoyt Stenmark, MD; John F Steiner, MD, MPH; Sanjana Marpadga, MSc; Marydale DeBor, JD; Kathleen Underhill; Hilary Seligman, MD, MAS
Traditionally, health care systems have addressed gaps in patients’ diet quality by providing dietary counseling and education. This article describes barriers and lessons from implementation and expansion of the Kaiser Permanente Colorado’s clinical food insecurity screening and referral program, operating in collaboration with a statewide organization (Hunger Free Colorado) to manage clinic-to-community referrals. Immediate goals are to identify households experiencing food insecurity, connect them to sustainable (federal) and emergency (community-based) food resources, alleviate food insecurity, and improve dietary quality, and additionally to improve health outcomes, decrease health care utilization, improve patient satisfaction, and better engage patients in their care.

Narrative Medicine

The Best Year of Angela’s Life
Kumara Raja Sundar, MD
Using a patient story, this narrative demonstrates why health care organizations, specifically primary care clinics, should strive to identify and 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.

sonnetA Social Needs Network for Evaluation and Translation

SONNET is committed to helping Kaiser Permanente leaders, front-line clinicians and staff design and evaluate effective interventions to address the social needs of our members.

sirenThe Social Interventions Research and Evaluation Network

SIREN is an initiative housed at the University of California, San Francisco. SIREN's mission is to catalyze and disseminate high quality research that advances efforts to identify and address patients' social risks in health care delivery contexts. It is supported by Kaiser Permanente and the Robert Wood Johnson Foundation.


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