May 27, 2022

The importance of connecting patients with social resources

In Oregon and Southwest Washington, Kaiser Permanente is helping members with social needs like food, transportation, and housing.

When community health navigator Liliana Herrera Acosta first spoke with Kaiser Permanente member Adriana (not her real name), a 29-year-old mother of 2 young children, Adriana’s cancer had recently spread to her liver and she  had decided to postpone her cancer treatment.

“Her family was already facing so many other challenges that she was just overwhelmed,” said Acosta. “They were financially insecure and behind on rent and utility payments. They couldn’t afford child care. Because of transportation issues, she had a hard time making it to appointments.”

Acosta is part of a Kaiser Permanente initiative that started in 2020 with the goal of helping members with social needs like food, transportation, and housing.

Making connections

Through the program, the health team proactively identifies members who need support, and pairs them with a community health navigator who makes weekly check-in calls for 3 months.

The initiative stems from a partnership with the University of Pennsylvania’s Center for Community Health Workers. Kaiser Permanente in the Northwest is using Penn’s IMPaCT model, which leverages community health workers to improve health. Use of the model has been shown to help people reduce hospitalization, increase primary care access, and improve quality of care.

“The goal is to connect patients with resources, but also to give them skills so they can help themselves,” said Sam Burke, a community health navigator at the Kaiser Permanente Rockwood Medical Office in Portland, Oregon.

Burke recently helped a 91-year-old member who wanted to continue living independently, but whose bathroom was in such a state of disrepair she feared she would have to move. Burke connected her with an agency that agreed to provide funding and labor for the repairs.

Screenings, social services, and more

The program is one part of a comprehensive Kaiser Permanente social health strategy in the Northwest that also includes screening for social health needs during patient visits, using Connect Oregon and Unite Washington to make referrals to — and build a network of — social service agencies, and designed to increase the availability of much-needed resources like affordable housing.

“There is no diagnosis that competes with social health issues in terms of prevalence,” said Briar Ertz-Berger, MD, Northwest Permanente medical director of social health and quality management. “We will continue to take care of patients in a vacuum if we don’t take care of their whole lives. And COVID has accelerated the need to address those foundational health issues.”

A matter of life and death

In Adriana’s case, these issues were literally a matter of life and death. Acosta was able to connect her with agencies that are now providing food, utility, and rent assistance. Adriana agreed to begin her cancer treatment.

“She said she doesn’t know what destiny has in store for her,” said Acosta, “But she wants to continue with her treatment so she can watch her children grow up. She was grateful we could help connect her to community resources, and that we listened without judgment during her difficult times.”