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
Addressing Social Determinants of Health - a KP Perspective | DII
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.
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.
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