Designing, implementing, and evaluating a new role to address social health needs in primary care

The challenge

When research sheds light on a new service or intervention that can improve care and patient health, often the challenge for health systems is figuring out how to implement and spread the intervention in a practical, patient-centered way. Kaiser Permanente Washington’s effort to address social needs in primary care is an example of how a learning health system can take on that challenge. This story start with a research study that sparked ongoing work to translate research findings into practice.

Back in 2014, a pilot study funded by the Patient Centered Outcomes Research Institute (PCORI) developed the Community Resource Specialist (CRS) role as a way to address social needs in primary care. The pilot study team included 2 patient co-investigators, ongoing input from patients in the design and evaluation of the project, and partnership with 2 Kaiser Permanente Washington clinics to test the new role. CRSs provide health and wellness support to patients and connect them to community-based resources for social needs such as housing, transportation, caregiver support, and healthy food access. The project’s evaluation found that 92 percent of patients were satisfied with the service, and care teams said having a CRS work with patients on community resource referrals gave them more time to provide other clinical services to patients. 

These promising findings led Kaiser Permanente Washington to make a commitment to hire CRSs in all its primary care clinics. However, there were many unknowns about this new role: What is the best way to integrate the CRS into the primary care team? What impact does the CRS have on patient outcomes? The ACT Center partnered with health system leaders to implement the CRS role systemwide and to evaluate the role's impact on patients and care teams. Our goals were to optimize the CRS service, enhance CRS program effectiveness, and inform ongoing decision-making about the program.

The work

• Define the core components of the CRS role
• Support CRS implementation through practice facilitation
• Document best practices and scale-up strategies
• Evaluate the impact of the CRS service on patient and care team outcomes and share lessons learned
• Develop a CRS Integration Playbook to help CRSs, CRS managers, primary care teams, and clinic leadership continue improving CRS services and the role’s integration on the care team

What we learned

The results from the CRS evaluation taught us that:

• The CRS role is valued by patients and care teams and reflects well on KPWA.
• Patients who had 2 or more CRS encounters reported positive changes and were very satisfied with the service.
• The CRS role can help address many unmet social needs for many patients, but patients may need significant support to overcome barriers to accessing resources and the stigma of asking for help.

Impact

Based on CRS evaluation results, our team recommended that KP Washington implement universal social health screening for all members. We are currently leading that work in partnership with Kaiser Permanente Washington leaders, care teams, and members and are continuing to learn about how to best meet people’s social needs in primary care settings.

Featured publications

The Impact of the Community Resource Specialist: Integrating a Lay Health Worker to Address Social Needs in Kaiser Permanente Washington Clinics. SONNET Newsletter, Vol 4, Issue 3. Sept 28, 2020.

Hertel E, Cheadle A, Matthys J, Coleman K, Gray M, Robbins M, Tufte J, Hsu C. Engaging patients in primary care design: An evaluation of a novel approach to codesigning care. Health Expect. 2019 May 27. doi: 10.1111/hex.12909 [Epub ahead of print] Full text

Hsu C, Hertel E, Johnson E, Cahill C, Lozano P, Ross TR, Ehrlich K, Coleman K, BlueSpruce J, Cheadle A, Matthys J, Chapdelaine M, Gray M, Tufte J, Robbins M. Evaluation of the Learning to Integrate Neighborhoods and Clinical Care project: findings from implementing a new lay role into primary care teams to address social determinants of health. Perm J. 2018; 22:18-101.Published online 2018 Oct 22.doi: 10.7812/TPP/18-101. PubMed