How health systems can advance social risk-informed care

New SONNET report offers recommendations to help KP and other health systems tailor care in the context of patients’ social risks 

An interview with longtime SONNET Evaluation and Research Committee (ERC) member Stephanie Fitzpatrick, PhD, and her colleague at Kaiser Permanente Northwest Center for Health Research, Dea Papajorgji-Taylor, MPH.

In 2021, Stephanie and Dea conducted a scoping review and qualitative interviews to paint a picture of the current state of the research on social risk-informed care and its implementation at Kaiser Permanente. Their new report synthesizes the latest evidence, interviews with Kaiser Permanente leaders and providers, and focus groups with members from all 8 regions. The result is a roadmap for effectively implementing social risk-informed care, including 21 specific recommendations across 6 domains: leadership, training, infrastructure, patient-provider interaction, community, and evaluation. 

What was the impetus for this research?

SF: Dea and I had previously worked with colleagues at Kaiser Permanente Northwest Center for Health Research to lead an early evaluation of the implementation of Thrive Local. So we already had experience looking at strategies to advance social health practice within our region.

When we learned that social risk-informed care was a priority area for SONNET, doing this scoping review and qualitative research seemed like a natural next step. Social risk-informed care involves tailoring members’ care plans to incorporate their social risks — for example, finding an alternative to mail order prescriptions for people who don’t have stable housing. Across Kaiser Permanente, we’re doing all this work to collect social risk data from members, but we don’t fully know what's happening on the clinical side.

DPT: Filling that knowledge gap is so important. In all our regions, we’re trying to incorporate social health screening for members and to think about the specific social needs and risks they might face. But, like Stephanie mentioned, we haven’t yet fully explored the clinical side of it. We've made it a priority to collect social risk information from our patients, but what are the expectations for Kaiser Permanente clinicians and care teams to incorporate that information into patient care plans?

SF: With this project, we wanted to make sure we were looking not just at Kaiser Permanente Northwest, but across all 8 regions — to get a holistic picture of what's happening and not happening with social risk-informed care. We also wanted to understand from the literature about what social risk-informed care should look like in practice.

In our scoping review, we learned that the literature on application and implementation of social risk-informed care is very limited. Of the more than 3,000 articles our team reviewed, only 14 met inclusion criteria for our review. More research is definitely needed in this area, which Kaiser Permanente is in a good position to lead.

What are some of the main things you learned in the scoping review, qualitative interviews, and focus groups?

SF: From the literature that’s available, it’s clear that social risk-informed care involves closely listening to patients and looking for nonverbal cues to identify and understand the contextual factors that might hinder their ability to manage their health. To do this, providers must take the time to build a relationship with the patient and adjust their care planning to incorporate identified social risks.

DPT: This echoes what we heard in the focus groups with our members. Many talked about the importance of having a good relationship with their provider. If a patient trusts their provider and feels heard and listened to, they are more willing to disclose information about critical things going on in their life. If they feel like the provider is not making eye contact, rushing through the visit, and not really listening to them, members are less likely to identify the social risks they’re experiencing.

SF: Among the providers we interviewed, having adequate training on how to effectively deliver social risk-informed care was identified as one of the  top priorities. Our report includes detailed recommendations for training topics, including examples of effective patient-provider interactions, and conveying how to effectively communicate with members regarding social risk topics.

DPT: These specific recommendations helped inform Kaiser Permanente’s new social risk-informed care training module, which was developed by a SONNET workgroup that I participated in. Part of the training includes components of motivational interviewing, and it shows several patient-provider scenarios conveying how to effectively engage patients in talking about social risks.

What else would you like to highlight about the recommendations in your report?

DPT: Collectively, we hope the recommendations will help make social risk-informed care part of the clinical culture — so that patients and providers understand that taking into account social risks is inherently part of the care we provide at Kaiser Permanente.

SF: This can be a tricky thing to achieve because there’s a lot that needs to happen all at once. One big theme that emerged in our qualitative research is the need for infrastructure — so that when physicians are trained to provide social risk-informed care, they have staff support, resources, and data tools built out to show them a patient’s social risk information.

One way to approach the recommendations would be to go through the list and say, “We're ready to start on leadership” or “We’re ready to start on training.” But if the infrastructure hasn’t been put in place, then how effective can the training really be? Together, the recommendations paint the full picture of what needs to happen for a health system to deliver social risk-informed care.

DPT: I would underline Stephanie's comment about infrastructure. In our qualitative work, we learned that Kaiser Permanente’s 8 regions are all at different stages and degrees of understanding what social needs and social risks are and how best to implement screening results in care planning. They also vary widely in having the data tools, workforce, and resources to be able to support that work. When these key infrastructure pieces aren’t in place before we press the “start” button on social risk-informed care, it leaves room for confusion or misunderstanding and can also lead to a lack of buy-in from clinicians, staff, and members.

What needs to happen next to advance social risk-informed care?

SF: In addition to investing in infrastructure, I think it’s important to invest in community resources and in evaluation. On the community side, we have to recognize that this work doesn't happen without genuine, meaningful partnerships with community organizations. And without an evaluation component, we’ll never know if our social health programs are making a meaningful difference for members.

Now that we have some foundational recommendations on how to implement social risk-informed care, I think we need some test cases. We need to actually implement and then study how the implementation goes so we can understand the long-term effects. We can build off of research by Dr. Saul Weiner and others to look in-depth at Kaiser Permanente’s new social risk-informed care training. And then eventually connect training outcomes to health outcomes and cost data. There's a huge opportunity for research in one region or across regions, and this is certainly something I could see being funded by the Patient Centered Outcomes Research Institute or the National Institutes of Health.

For example, Dr. Weiner and his team developed the Content Coding for Contextualizing Care (4C)*, a method used to determine to what degree contextualized care ─ or in our case, social risk-informed care ─ is being delivered during an encounter. Kaiser Permanente has the opportunity to contribute in this space by using both member and community voices to reflect on tools and methodology like this to identify what's missing or how can it be improved or tailored across regions.

DPT:  It would be interesting to do a qualitative study that looks more closely at the provider-patient interaction after the training is rolled out. We need to understand how effective the training is and the trends in which providers are taking it and what the barriers might be. But we also need to understand how social risk-informed care is landing with patients.

* Weiner SJ, Kelly B, Ashley N, et al. Content coding for contextualization of care: evaluating physician performance at patient-centered decision making. Medical decision making: an international journal of the Society for Medical Decision Making. 2014;34(1):97-106.

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