1. Addressing social needs of Kaiser Permanente members: a project and a network
John F. Steiner MD, MPH, Institute for Health Research, KP Colorado
Presentation to NOPREN, November 27, 2017

2. Outline
Why has KP prioritized addressing the social needs of its members?
Food insecurity screening in elderly members of KP Colorado
The SONNET Network
Rationale
Organization
Preliminary activities
November 27, 2017
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

3. KP’s Vision for Addressing Members’ Social, Economic and Behavioral Needs (SEBN)
In partnership with communities, KP should identify and address individuals’ most pressing basic human needs as a standard part of quality healthcare and to achieve health equity.
Goal
KP will devise and execute on a plan that addresses the Social, Economic, & Behavioral Needs of KP members to achieve better health at lower cost.
Key Capabilities/Functions
1. Assessment:
Understand and document social needs
2. Navigation:
Connect patients to the right resources
3. Partnership:
Collaborate/partner with community resources
4. Evaluation, Learning & Spread:
Evaluate to build the evidence and inform spread/scale
November 27, 2017
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

4. Social Needs and the KP Mission
Efforts to identify and address social needs are consistent with KP’s mission – “to provide high-quality affordable health care services and to improve the health of our members and the communities we serve”.
Diverse membership – a “blue collar” HMO
Social needs are more prevalent among members than many would expect in a private-sector insurer/delivery system
KP has mitigated but not eliminated health disparities using the “rising tide” model of quality
KP participation in federal programs has increased
Medicare Advantage (long-standing role, high quality of care, declining Medicare payments)
Medicaid (increase since ACA enacted)
Exchange participation (likewise)
November 27, 2017
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

5. Food insecurity in the Elderly in KPCO
In 2015, 8.3% of US households with an elderly member (9.2% of elders living alone) reported food insecurity
In 2015, KPCO cared for 110,000 members age 65 and over
Mostly Medicare Part C (Medicare Advantage)
7-8% dual eligible for Medicaid programs (traditional or Special Needs Program)
KPCO offers a no-cost Annual Wellness Visit as an option for Medicare members, with a preceding survey to
Identify functional concerns (bathing, shopping)
Identify geriatric syndromes (falls, urinary incontinence)
Identify some social needs (more in v2.0)
November 27, 2017
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

6. Food Insecurity Question
“Do you always have enough money to buy the food you need?”
Yes/No
From the DETERMINE Your Nutritional Health scale developed by the Nutrition Screening Initiative *
* BM Posner et al. Am J Public Health 1993;83:
November 27, 2017
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

7. 50,131 Members Completed MTHA (38%)
130,316 Elderly Members 1/2012 – 12/2015
50,131 Members Completed MTHA (38%)
2,863 Members with Food Insecurity (5.7%)
47,268 Members without Food Insecurity (94.3%)
November 27, 2017
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

8. Clinical Characteristics and Food Insecurity
Prevalence of food insecurity
Male / female
5.0% / 6.0%
Age: / / 85+
5.5% / 5.9% / 4.6%
White / African-American / Latino / Other
4.8% / 15.5% / 10.0% / 6.8%
Medicaid: No / Yes
5.1% / 24.0%
Married or partnered / single
4.5% / 7.9%
Diabetes: No / Yes
5.1% / 7.8%
BMI: Underweight / normal weight/ overweight / obese / extremely obese
7.2% / 4.9% / 5.2% / 6.3% / 10.0%
November 27, 2017
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

9. Health Status and Food Insecurity
Characteristic
Prevalence of food insecurity
General health: excellent + very good / good / fair + poor
4.1% / 6.7% / 10.8%
Quality of life: excellent + very good / good / fair + poor
4.1% / 7.5% / 13.2%
Eating: do myself / have difficulty or need help
5.5% / 13.1%
Managing money: do myself / have difficulty or need help
5.1% / 14.6%
Shopping for groceries: do myself / have difficulty or need help
4.2% / 10.6%
Lonely or isolated: never + rarely / sometimes, often, always
4.9% / 9.4%
Someone I could call for help: Yes / No
5.4% / 15.7%
November 27, 2017
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

10. Clinical Characteristics and Food Insecurity
Risk quintile *
Prevalence of food insecurity
0- 20% (lowest risk)
1.5%
21-40%
2.9%
41-60%
3.9%
61-80%
5.9%
81-100% (highest risk)
14.4%
* Risk model based on 23 variables from the KPCO electronic health record and MTHA survey (C-statistic = 0.73)
November 27, 2017
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

11. 184 elderly members with food insecurity on MTHA
110 (60%) completed survey to identify other social needs
81 members with food insecurity on Hunger Vital Sign (74%)
29 members with no food insecurity on Hunger Vital Sign (26%)
November 27, 2017
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

12. Other Social Needs and Food Insecurity
Characteristic *
Food insecure (N =81)
Not food insecure
(N = 29)
Income < $15,000/year
53%
12%
Concerns about housing
68%
31%
Concerns about paying for necessities
98%
66%
Concerns about transportation
28% 3%
Cost-related medication non-adherence
70%
21%
Difficulty paying for utilities
34%
14%
Number of other basic resource domains
2.9
1.3
All p<0.05
November 27, 2017
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

13. Tradeoffs between resource needs
In the last 3 months, did you put off paying for one item in order to pay for something else?
(never, rarely, sometimes, often)
Put off paying for food to pay for housing
Put off paying for housing to pay for food
Put off paying for food to pay for utilities
Put off paying for utilities to pay for food
Put off paying for food to pay for medical needs
Put off paying for medical needs to pay for food
Put off paying for food…
Put off paying for…
p-value
… to pay for housing (47%)
… housing to pay for food (22%)
< 0.001
…to pay for utilities (47%)
… utilities to pay for food (31%)
0.001
…to pay for medical needs (36%)
… medical needs to pay for food (32%)
0.39
November 27, 2017
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

14. Evaluation Framework: Continuum of Care
Identification
Community-Clinic Integration
 Outcomes 
November 27, 2017
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

15. Other Components of Evaluation
Mapping the referral process and flow of information between KPCO and Hunger Free Colorado (statewide, community-based food resource connector)
Many inefficiencies in this complex system
Collaborating with Hunger Free Colorado on a survey of KPCO members who have used their hot line
Food resources obtained
Duration resources used
Alleviation of food insecurity
Satisfaction with HFC and KP services
Assessing relationship between food insecurity and clinical outcomes for diabetes, hypertension
November 27, 2017
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

16. A learning network of KP researchers and evaluators committed to:
helping leaders and clinicians in KP design interventions that address the social needs of members,
using KP’s data and resources to inform evaluation,
using “advanced analytics” to target interventions towards members who need them,
systematically sharing learnings in order to scale up what works, and
stop doing what doesn’t work.
November 27, 2017
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

17. Goals
To connect:
LINK social needs researchers and evaluators to share methods and findings.
IDENTIFY ongoing interventions to address social needs across KP regions.
COMMUNICATE the findings of these interventions.
REFINE social needs interventions for clinical and operational spread.
November 27, 2017
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

18. Goals
To consult:
ENGAGE new social needs programs early in their planning process.
HELP operational and clinical leaders:
standardize measurement of social needs and relevant outcomes; and
promote evaluation designs that provide actionable evidence of program effectiveness.
November 27, 2017
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

19. Goals To translate DEFINE the extent of social needs among KP members.
ANALYZE existing KP data to identify members at highest risk.
IDENTIFY the content and context of effective programs.
DISSEMINATE AND ADAPT those programs within and between KP regions.
November 27, 2017
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

20. First year activities
Update KP’s current inventory of social needs interventions
Synthesize evidence for effectiveness of existing KP programs
Support interventions in KP Medicaid population
Develop protocols for consultation, and build network cohesion through group consultations
November 27, 2017
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

21. Each question raises new ones…
In a system with lower prevalence of social needs than the US population, should we screen all members or those at highest risk?
Social determinants meets Bayes’ Theorem
Which member subgroups should we focus on?
Medically complex, high utilizers
Medicaid
Most vulnerable (extremes of age)
Can we refine our ability to identify high-risk members using other social and behavioral information?
Incorporate neighborhood-level predictors
Other EHR data (adherence to appointments, meds…)
How do we assess success in addressing social needs?
November 27, 2017
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

22. Steering Committee Mateo Banegas, PhD, MPH, MS, KP Northwest
Jim Bellows, PhD, MPH, KP Care Management Institute
Rachel Gold, PhD, MPH, KP Northwest
Cara Lewis, PhD, KP Washington (formerly Group Health)
Julie Schmittdiel, PhD KP Northern California
Adam Sharp, MD, MS KP Southern California
John Steiner, MD, MPH KP Colorado (SONNET Director, )
November 27, 2017
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.