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Kaiser Tackles Social Determinants of Health Through EHR Interface With Community Organizations

Analysis  |  By Mandy Roth  
   May 13, 2019

4 ways this initiative may impact healthcare for millions.

In three years when one of Kaiser Permanente's members has a need related to social determinants of health, a referral to an appropriate community organization will be as simple as ordering a test from within the electronic health record (EHR). And, once the platform and network are established, the Oakland, California, nonprofit integrated health system plans to open the "Thrive Local" program to other interested health plans and health systems.

To launch this initiative Kaiser Permanente is partnering with Unite Us, which develops software that connects health and social service providers through the EHR. By the first quarter of 2020, each of Kaiser's eight regions, which operate in eight states and the District of Columbia, and currently serve 12.2 million members, will have a pilot in effect. Kaiser is already engaged in other initiatives to address  social determinants of health, such as affordable housing.

Thrive Local's social services directory will be continuously updated, providing access to a network of nonprofit public and private resources that address needs related to housing, food, transportation, safety, utilities, and more.

Because so many health systems are exploring ways to address social determinants of health, and Thrive Local has the potential to impact millions of individuals, HealthLeaders spoke with Imelda Dacones, MD, president and CEO of Northwest Permanente about four ways this initiative can help improve healthcare.

1. Improves Individual Outcomes and Population Health

The hope is to improve the health of individual patients and impact social determinants of health on a grand scale, says Dacones.

"We know that total health is really a summation of medical interventions, as well as socioeconomic interventions," she says. "One cannot have total health without addressing socioeconomic needs."

She continues, "We know that 60% or more of the health outcomes that impact our patients occur outside of [Kaiser Permanente's] walls. We're really getting [our] arms around all those things that impact our patients, our populations, and our communities outside of our reach and creating a more holistic intersection between the social and medical sectors to begin to address total health. It's a natural evolution of what we've been trying to do at [Kaiser Permanente} since day one."

Data generated by Thrive Local also may deliver additional benefits, Dacones says. Among the possibilities:

  • Enable Kaiser to determine how addressing social determinants of health impacts the overall health of its patients collectively, by disease state, and individually
  • Pinpoint lack of community resources. For example, the data might identify the need for transportation services in a particular zip code.
  • Become a useful resource to community agencies, providing hard data to help drive and secure funding

2. Creates Efficiencies That Benefit Patients and the Organization

Once someone within the Kaiser system—including social workers, navigators, nurses, or physicians—identifies a patient with a need, they can search from within the EHR for a local agency to address the issue. Currently, that person may need to make "15 to 30 phone calls" to identify an appropriate resource, says Dacones. Converting from a manual to an automated process will create tremendous efficiencies for employees and patients, she says. Once a referral is made, the outside organization can then send secure messages back to the provider, ensuring the patient has connected with the service.  

Because referrals are visible in the EHR, she says that the system will prevent Kaiser patients from having to repeat sensitive information during each encounter with the organization.

"We don't have to keep unintentionally traumatizing our patients and their families by asking the same questions over and over again," says Dacones, who is an internist and former hospitalist. Employees in the emergency department, hospital, or clinic will be able view in the EHR, for example, whether an individual has been referred to an organization that addresses intimate partner violence or housing, for example, she explains. "Having all the social as well as medical sectors on the same page about what's going on with this person is another great outcome."

3. Delivers Data to Influence Policy and Funding for Community Organizations

Being able to identify food or transportation deserts or other areas of need can help Kaiser with advocacy efforts, says Dacones. "We'll be able to have a data-driven conversation with policy makers, and public and government agencies. This will begin to give very granular detail as to where in the communities these things are missing."  

By the same token, this information can help community-based organizations advocate for the needs of their constituents by better understanding their anticipated volumes and capacity. The shared platform also will enable them to determine their own impact, performance, and patient outcomes.

"For the whole ecosystem," says Dacones, "it's a win-win."

Once the network is operational, opening it up to other health plans and systems is necessary, she says, "because ultimately it's going to take the community of the United States if we're really going to impact the most vulnerable populations."

4. Helps Address Physician Burnout

Although Dacones is no longer practicing medicine, she says Thrive Local has the potential to improve physicians' disillusionment with healthcare.

"One of the things that eats at your soul is [when a patient returns and you think,] 'I just saw you a month ago for the same problem, and I'm admitting you again' " she says. "For me the joy in medicine is when you feel like you've had an impact on the whole person, and this is what [Thrive Local] has the potential to do."

Editor's Note: The second sentence of the story has been modified to clarify when the program will be available to other health plans and health systems.

Mandy Roth is the innovations editor at HealthLeaders.

Photo credit: Courtesy of Kaiser Permanente


Software links Kaiser with searchable list of community organizations through the EHR.

Data will measure how the initiative impacts overall and individual patient health.

Program will identify locations with needs, such as food or transportation deserts.

Information may help community organizations advocate for funding.

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