2017 Southern California Dissemination, Implementation and Improvement (DII) Science Symposium Identifying, Addressing, and Understanding Social Determinants of Health: A Kaiser Permanente Health System Perspective Adam Sharp, MD, MS - Kaiser Permanente Southern California Artair Rogers, MS - Kaiser Permanente Southern California For more information on DII, go to: https://ctsi.ucla.edu/patients-community/pages/dissemination_implementation_improvement

1. Identifying, Addressing and
Understanding Social Determinants of
Health: A KP Health System Perspective
Artair Rogers, MHA
Adam L. Sharp MD, MS
Care Improvement Research Team
Department of Research and Evaluation

2. Agenda
 Overview of Health Leads Pilot Implementation
 Evaluation Plan
 Patient Perspective
 Improvement Process
 Discussion

3. Implementation Strategy: Region Level
Pilot at 3 Diverse Centers
 West LA, Fontana, Kern
Community Resource Hub
 Regional call center
 Central screening of
predicted high utilizers
 Connecting those with
needs to resources
 Evaluating outcomes

4. Implementation (CFIR)
Characteristics of
the Intervention
 External vendor
needed to increase
capacity
 Low cost
 Adaptable
 Centralized and
Spreadable
 Screening,
Navigation, and
Follow Up
Inner/Outer
Settings
Individuals Involved
Implementation
Process
 High Utilizers
 Engaged
Stakeholders
 Call center (CRH)
 Resource
database
 Evaluation Team
 KP culture
 Expected Need
 Increasing
Demand
 Government and
Health Care
Sector’s Growing
Interest

5. Community Resource Hub
Screening Funnel
0%
20%
40%
60%
80%
100%
Cold Call Screen Identify Needs Enroll
73%
agree to take
screen
55%
have 1+ need
38%
enroll
66%
answer call
How many members are screening positive?
N= 4,101
answer call
N=2,999
took screen
N=1,641
screen positive
N=625
enrolled
11/15/15 to 3/31/2017
N=6,220 members called

6. 6
Social Need Prevalence
What are members screening positive for?
 Caregiver support
(52%)*
 Financial (37%)
 Affording healthy meals
(29%)
 Food didn’t last (29%)
High Prevalence Medium Prevalence Lower Prevalence
 Utilities (24%)
 Social isolation (24%)
 Transportation (22%)
 Medical care costs
(20%)
 Health
literacy/numeracy
(16%)
 Applying for public
benefits (12%)
 Housing conditions
(11%)
 Financial counseling
(9%)
 Employment (6%)
 Homelessness (6%)
 Housing Safety (5%)
 Child-related (5%)*
*12% of pilot population identified as caregivers of an individual
who is physically or mentally disabled.
*51% of pilot population identified as not being a caregiver of
children.

7. Mixed Methods Evaluation Underway
 Descriptive analysis of social needs
 Patient/Provider Interviews
 Patient/Provider Surveys
 Quantitative analysis: utilization/costs/outcomes
– Propensity scored difference-in-difference comparison
– Randomized screening

8. Members’ Perspectives from Focus Groups*
 Members want a one-stop shop. Call back information is desired.
 Patients do feel comfortable sharing their information with community
resource organizations if permission has been given.
 An action plan that allows members to understand end goals and
highlights next steps is desired. Follow-up schedule guided by patient.
 Members ultimately value being given information about community
resources but may experience barriers such as:
– (1) pre-existing negative impression of the recommended organization and
wanting more information from navigators
– (2) discovering that they do not qualify for services
– (3) administrative barriers with the community organization, and
– (4) unfeasible wait times for some services (example: transportation must be
scheduled two weeks in advance)
*Themes derive from member phone interviews and focus groups conducted in
partnership with Care Management Institute’s Evaluation Team.

9. Effort Required to Address Social Needs
9© 2017 National Quality Conference © 2017 Kaiser Foundation Health Plan, Inc. For internal use only.

10. Evolution of Performance Improvement
Strategy
• Number of
Answered Calls
(time study)
• Number of
Individuals
Screened (scripting)
Phase 1
• Motivational
Interviewing
• Removing Additional
Barriers
• Setting Long Term
Goals
Phase 2
(in progress) • Understanding the
Positive Deviances
• Creating Social Need
Pathways
• Seasonal Resources
Phase 3
(in development)
Resulted in 66 percent of all members
called answering cold call; ~50% of those
who answered agreed to be screened for
social needs
Opportunities for Improvement:
• Increasing Number of Patients Enrolled in Navigation
Support (28% avg.; 18% low at end of year)
• Increase Number of Successful Connections

11. COMMUNITY RESOURCE HUB 2017
COHORT 1
MEMBERS WHO SCREENED
POSITIVE AND PREVIOUSLY
DECLINED HL SERVICES
580
246 98
COHORT 1
PATIENT
LIST
POSITIVE
SCREENS
ENROLLED
40%
MEMBERS WHO
SCREENED POSITIVE
ENROLLED IN SERVICES
Updated: 4.19.2017

12. Q+A
© 2017 National Quality Conference © 2017 Kaiser Foundation Health Plan, Inc. For internal use only.12