Kaiser Permanente, the nation’s largest integrated health delivery organization, launched its Total Health initiative in 2014 to promote healthy eating and active living among our members. We have now begun to bolster that effort by aiming to target our members’ unmet social needs as part of their overall health care. After all, social, environmental, and behavioral factors account for an estimated 60% of health, compared with just 10% from factors traditionally defined as “clinical.” And research shows that nations that focus on food insecurity, housing, transportation, and other “nonmedical” factors spend less overall on health care while improving quality and quantity of life.
The most sensible starting point in addressing unmet social needs is, of course, the costliest patients — the roughly 1% of our members (40,000 of the more than 4 million in southern California) who incur 23% of our total health care spending. Evidence shows that most health care strategies fail the top 1% of spenders — the high-cost, high-need super-utilizers or, to use Atul Gawande’s term, “hot spotters.”
To meet these patients’ needs, we recognize that we must do more than provide top-quality care in hypertension control, immunization, cancer screening, cardiovascular disease management, asthma, diabetes, and other clinical areas — all of which have garnered us national recognition. So we set out to develop a scalable approach that, by targeting the social determinants of health, improves patients’ overall well-being while complementing our system’s current offerings.
That doesn’t mean that Kaiser Permanente should, for instance, build affordable housing for homeless people who enter our doors. But it does mean taking on the responsibility for the full scope of our patients’ needs, consistent with our social mission and business imperative to improve the health of the communities we serve. We believe that adopting a “whole patient” perspective for our high-cost, high-need patients will give us the best chance of improving their health outcomes. To achieve this goal, we aim to partner with existing community resources, identify gaps in linking with those resources, and (in the process) demonstrate the value of directly addressing the social determinants of health.
How We Reach the Neediest Patients
Physicians generally lack the training and resources to fully assess patients’ unmet social needs and to identify and work with community-based organizations that can meet them. That task requires a total skill set that only a team-based approach can offer. So, beginning in 2015, Kaiser Permanente partnered with Health Leads, a social enterprise organization that aims “to address all patients’ basic resource needs as a standard part of quality care.”
With Health Leads’ expertise, Kaiser Permanente is developing several initiatives as part of a carefully designed pilot project. The most scalable approach is a call center that proactively reaches out to patients we identify as being at highest risk of becoming super-utilizers (i.e., in the top 1% of predicted utilization according to their illness burden). Trained KP call-center workers cold-call these members to ask about their unmet social needs. So far, we have called 876 members, 69% of whom answer the phone.
The call-center staff person starts by asking the member whether he or she would like to participate in a phone-screening session about social needs that affect health and well-being. If the member agrees (76% of those who pick up the phone do), he or she is asked a set of screening questions, some of which are shown in the table.
We have found that 78% of screened members have at least one unmet social need (mean, 3.5). Of the people with unmet needs, 74% (or 21.2% of all the members we call) agree to enroll in Kaiser Permanente’s Health Leads program, which connects them with existing resources in the community (e.g., food banks, tenants’ rights associations) or at Kaiser Permanente (e.g., member financial assistance). So far, we have enrolled 186 members in community-based social-needs programs. To ensure quality and patient safety, the call-center team partners with local social-medicine and case-management teams if social needs beyond the call center’s scope of services arise.
Enrolled members are called every 10 to 14 days, to further assist them in connecting with resources and to assess how well their needs are being met. We are in the process of analyzing the success of our referrals to outside agencies (e.g., which is the best food bank?) so that we can better understand the resource gaps within a defined geography; develop a community-alignment strategy, in partnership with community-based organizations, to address those gaps; and ultimately increase the number of successful resource connections for our members.
Here’s what data from Health Leads show: Of the 25,000 resources across 8 geographies in its database, just 1% of resources account for 50% of successful connections, and 10% of resources account for 90% of successful connections. We aim to start using these findings to emphasize connections with the highest-yield community resources. In addition, in other pilot projects, we are assessing the quality of in-person assessments of social need in various care settings (e.g., ambulatory clinics, home health, inpatient units) and the success of what we call “warm handoffs,” whereby clinicians preliminarily identify a patient with a social need and refer him or her to the call center.
Few attempts have been made, at scale, to identify and close gaps in social (nonmedical) needs. Our call center — using a well-trained, nonclinical workforce — is a low-cost model for assessing the social needs of patients and helping them navigate available resources. Early indicators show a high prevalence of social need among our high-cost, high-need members and suggest likely downstream effects on health care utilization and clinical outcomes.
The definition of what counts as health care is expanding. Health care systems can responsibly steward and amplify shared economic, human, and community resources to deliver high-value care within and beyond a provider’s walls. Our pilot project at Kaiser Permanente, focusing on patients’ unmet social needs, is one concrete step in that direction.
Acknowledgment: Adam Sharp, MD, and Adam Schickedanz, MD, helped to lead this work at Kaiser Permanente, Southern California. We also thank Rebecca Onie, Alexandra Quinn, and Kelly Hall at Health Leads for their insightful guidance — and Arthur Southam, MD, and Raymond Baxter, PhD, for their partnership and leadership.