Kaiser Permanente building infrastructure to 'connect the dots' for social determinants

Kaiser Permanente plans to roll out a new care network to more effectively connect its 12.3 million patients to the community services they need, such as housing, food, or transportation.

The health system is partnering with Unite Us, a social determinants technology and care coordination platform, to build the technology infrastructure that will enable Kaiser Permanente to better address social determinants and  "connect all the dots in a systematic way" for its millions of members, Kaiser Chairman and CEO Bernard Tyson told FierceHealthcare.

The initiative aims to equip all of Kaiser Permanente's healthcare providers with technology tools to better address patients' social determinants of health. The health system plans to start rolling out the network regionally this summer. The goal is to make the network available across its entire system within three years to serve the 68 million people in the communities it serves.

Called Thrive Local, Kaiser Permanente officials said it would be the most comprehensive, far-reaching social health network of its kind to connect health care providers and social services. The program will enable providers and caregivers to seamlessly match an individual's social needs with the appropriate services from within a robust network of nonprofit, public and private resources, Kaiser officials said.

"We built networks for primary care and for specialty care, now we're saying we need a network for social health organizations," Bechara Choucair, M.D., chief community health officer at Kaiser Permanente told FierceHealthcare.

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The network of resources will be integrated into Kaiser Permanente's electronic health record (EHR) system. "By integrating this network into our clinical care, our members with unmet social needs will be connected to community services more efficiently," Choucair said.

The network, which will also be available to community health centers and community-based organizations, will track community partner referrals and service outcomes to measure the degree to which participants' needs are met—gathering data to continuously improve service delivery and better address community conditions for health. 

While Choucair wouldn't specify how many social care organizations would be included in the network, he said the health system would work "community by community" to identify the resources available and the social care needs of the local community. "Unite Us has a strong track record in engaging nonprofit and community-based organizations and they do have a large network already across many states. They are engaged with over 7,000 community-based organizations," he said.

Kaiser Permanente also is an investor in New York City-based Unite Us. "We have an equity stake in the company because we believe it's great technology and a great model," Tyson said. "That relationship allows us to partner with them at another level. It brings us together in a tighter, more strategic way."

Tyson said the initiative builds on Kaiser Permanente's philosophy of operating as a "holistic health system" with a focus on physical, mental and social care.

"In order to thrive, people need access to the things that are vital to health such as secure housing and nutritious food. Our unique mission to improve not only the health of our members but also that of our communities drives us to undertake impactful initiatives like Thrive Local to connect our communities with the services they need. This is one of our bold moves," Tyson said.

"We see many organizations starting to do much more of this and it really does represent the future of what’s possible now with health organizations," he said.

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Recent data indicates that in certain regions, up to 29% of Kaiser Permanente's members that have the greatest medical challenges are dealing with food insecurity, and as many as 23% have concerns about housing stability. These are critical issues among the types of challenges that Thrive Local will address, Tyson said.

"Where and how people live, work and play drive more than half of health outcomes. To address total health, we, as physicians, need systems and networks that address our patients' social needs," Imelda Dacones, M.D., president and chief executive officer, Northwest Permanente, said in a statement. 

Dacones said health care needs to evolve from acute episodic care to an integrated coordinated system focused on prevention and coordinated care management. "This tool will accelerate our evolution as a sector to next-generation care delivery—a community-integrated model that connects physicians, our patients and health care systems to community resources that address our patients' socioeconomic needs."

The initiative is the latest effort by the health system to broadly address social determinants. 

In January, Kaiser announced it would put $200 million toward initiatives targeting housing insecurity and homelessness in the communities it serves. Its first investment was the $5.2 million purchase of an affordable housing complex in Oakland, California. Kaiser and Enterprise also said they would launch a $100 million loan fund to create or maintain affordable housing units in all of the communities Kaiser Permanente serves.

In March, the health system said it will provide $3 million over a three-year period toward ending chronic homelessness in 15 of its patient communities. The health system is partnering with the Community Solutions' Built for Zero initiative, which uses real-time data to help community leaders understand the dynamics of homelessness in their respective communities.