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Perm J. 2024; 28(2): 26–35.
Published online 2024 May 10. doi:10.7812/TPP/23.113
PMCID: PMC11232908
PMID: 38727254
Meagan C Brown, PhD, MPH,
1,2 Andrea R Paolino, MA,3 Katheen A Barnes, MD, MPH,4 Dea Papajorgji-Taylor, MPH, MA, CCRP,5 Loel S Solomon, PhD, MPP,6 Cara C Lewis, PhD,1,2 Elizabeth Bojkov, MPH, BSN, RN,2 and Katie F Coleman, MSPH1
Author information Copyright and License information PMC Disclaimer
Associated Data
- Supplementary Materials
Abstract
Introduction
Adapting clinical care decisions for patient-reported social risks is essential to social health integration and patient-centered care. Most research in this area focuses on awareness and assistance (social-needs-targeted care), such as screening and referral to food, financial, and other resources. Limited evidence for adjustment strategies (social risk–informed care) or adapting care for social risks made it difficult for Kaiser Permanente to implement new initiatives. This article describes a codesign process to build a novel, adjustment-focused continuing medical education course.
Methods
The authors codeveloped the online continuing medical education course with patients and clinicians using user-centered design. Transcripts from codesign activities were coded and analyzed by thematic analysis to identify major themes, including perceptions of social risk–informed care and barriers to care adjustment.
Results
Practical hurdles for implementing social risk–informed care emerged, including clinicians’ concerns about the ethics of adjustment as substandard care, particularly without robust assistance activities. However, patients expressed a desire for their care to be adapted to their social circ*mstances, to allow for more realistic care plans.
Discussion
Implementation barriers identified from the codesign were addressed through an interactive, case-study approach. Existing evidence on contextualized care and shared decision making informed a general framework for primary care providers to engage in awareness and adjustment activities, paired with 3 interactive case studies based on real-world, clinician-supplied scenarios.
Conclusion
The authors recommend that multiple stakeholder perspectives be incorporated during the development of social health integration initiatives, particularly adjustment. Education complemented by active, nuanced, flexible implementation strategies may be necessary for the successful uptake of care-delivery-based social health integration activities.
Keywords: social needs, social risks, social health, standard of care, social determinants of health, training, quality of health care
Introduction
Mounting evidence indicates that social factors contribute more to overall health and health disparities than health care.1–4 In response to this growing recognition of how upstream social determinants shape health outcomes, delivery systems and agencies, including the National Committee for Quality Assurance and the Centers for Medicare and Medicaid Services, are now addressing nonmedical social factors that impact health, in addition to physical and mental factors.5–7 Whereas nonclinical settings, including community-based organizations, have worked to respond to individuals' social risk factors, the use of integrated health care models to address these needs is relatively new and evolving.8,9 The 2019 National Academies of Sciences, Engineering, and Medicine (NASEM) report Integrating Social Care into the Delivery of Health Care identified 5 activities for health care systems to engage in social health integration activities: 1) awareness through identification of social risks, 2) adjustment by altering care that acknowledges patients' social circ*mstances, 3) assistance through resource connection, 4) alignment of health systems with community resources, and 5) advocacy by promoting policy change.10 Kaiser Permanente, guided by the NASEM framework,9 is supporting a range of activities to improve the social health of members and their communities (Table 1).
Table 1:
Kaiser Permanente’s Approach to Operationalizing NASEM’s 5 Domains of Activities to Advance Social Health
| NASEM activity | NASEM definition | Kaiser Permanente activities | Kaiser Permanente activity definitions |
|---|---|---|---|
| Awareness | Activities that identify the social risks and assets of defined patients and populations | EHR-embedded social determinants of health visual (Epic SDoH Wheel) Standardized and universal screening On-demand self-screener for member self-service | Piloting in 3 regions in a community of practice Standard screening questions added to Kaiser Permanente’s EHR to assess members’ social risk and/or needs Universal screening strategies to increase screening volume, including emailing digital screeners to members before well-visits, tablet-based questionnaire in waiting rooms, and automated IVR screening calls One-question, on-demand screening added to kp.org for members to self-report social needs and choose from a menu of support options |
| Assistance | Activities that reduce social risk by providing assistance in connecting patients with relevant social care resources | Web-based closed-loop referral platform for Kaiser Permanente and the broader community Connections call center Online community resource directory on kp.org Member-focused social health initiatives | Kaiser Permanente implemented Thrive Local, a web-based closed-loop referral platform for Kaiser Permanente and the broader community Kaiser Permanente opened a national call center with agents who screen callers for social needs and use the referral platform to provide resources Kaiser Permanente added a community resource directory to its website, kp.org, to allow visitors to search for local resources on their own Kaiser Permanente has direct-to-member outreach campaigns and other programs to help eligible members apply for public benefit programs, including SNAP, WIC, GetYourRefund.org, and the Affordable Connectivity Program |
| Adjustment | Activities that focus on altering clinical care to accommodate identified social barriers | Online continuing medical education course | SONNET sponsored an evidence review, interviews with representative primary care providers, and codesign of the content and format with clinicians and patients |
| Alignment | Activities undertaken by health care systems to understand existing social care assets in the community, organize them to facilitate synergies, and invest in and deploy them to positively affect health outcomes | Partnering with other health systems and public agencies in shared communities Applying member social health data to deepen understanding of community needs (informing CHNA, community investment strategies) | Kaiser Permanente partners with Blue Shield of California and CommonSpirit Health in several locations in California to build community-based organization referral networks Kaiser Permanente provides grants to facilitate participation by community-based organizations in the networks (eg, infrastructure upgrades, capacity expansion). Kaiser Permanente works closely with pre-existing systems to address social needs, such as 211 referral agencies and population-specific social service networks Kaiser Permanente shares member social health data with community health managers who are accountable for the CHNA and community investment strategy |
| Advocacy | Activities in which health care organizations work with partner social care organizations to promote policies that facilitate the creation and redeployment of assets or resources to address health and social needs | CityHealth, a foundation partnership promoting community health policies; White House Task Force on Hunger, Nutrition, and Health | Collaborations with charitable foundations, nonprofit organizations, and others to advance research, education, and policy solutions that promote health |
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CHNA, Community Health Needs Assessmen; EHR , electronic health record; IVR, interactive voice response; kp.org, Kaiser Permanente public website; NASEM, National Academies of Sciences, Engineering, and Medicine; SDoH , social determinants of health; SNAP, Supplemental Nutrition Assistance Program; SONNET, Social Needs Network for Evaluation and Translation; WIC, Women, Infants and Children.
Alongside support for social-risk screening (awareness) and referrals to social services (assistance), Kaiser Permanente seeks to support physicians and other care team members in the adjustment of clinical care based on a patient’s social risk.10 Studies of social risk–informed care, such as providing telehealth visits for patients who struggle with transportation, show that adapting care can improve patient health through intermediary outcomes such as reducing missed appointments and emergency department visits and improving adherence to medication and care plans.11–13 Additionally, risk–informed care improves (Supplemental Appendix 2 and 4) the interactions between patients and primary care providers and reduces clinician burnout.11–14 Although social risk adjustment leads to higher-quality, patient-centered care,11–13 health care organizations have no guidebook for working with clinical teams on using social needs screening data to adjust and improve care.10,15 Furthermore, meaningfully engaging clinicians in care adjustment means changing workflows and training strategies, which also requires guidance.10
Kaiser Permanente has 8 regional markets that vary in operations and social health integration practices. In one region already piloting universal social needs screening, the authors saw signals that primary care providers missed opportunities to adjust care plans despite having social screening data available in the electronic health record.16
In response, Kaiser Permanente’s Office of Community Health and its Social Needs Network for Evaluation and Translation (SONNET), in collaboration with national social health leaders, developed an asynchronous, scalable, web-based continuing medical education (CME) course for training Kaiser Permanente clinicians (physicians, nurse practitioners, and physician assistants) on social health adjustment. SONNET is a national network of embedded researchers who rigorously evaluate member- and community-centered interventions and apply evidence to inform social health operational strategies.17 A scoping review by SONNET researchers found only 14 studies related to adjustment or social risk–informed care.15 Given the lack of available adjustment guidance, the authors used a multistakeholder-driven approach to guide training development. This article reports on the codesign process and major themes that arose with important implications for research, scale, and spread of adjustment and social health integration.
Methods
Setting and participants
Codesign occurred from July 2021 to April 2022. The authors prioritized incorporating perspectives from various regions and roles. Four groups were engaged in the codesign process (Table 2): 1) a core team of primary care providers and researchers with experience in professional development and online CME design, working closely with Kaiser Permanente’s internal instructional design department to develop and refine training objectives, content, and design; 2) an advisory committee of primary care providers and researchers both internal and external to Kaiser Permanente, meeting monthly with the core team to provide subject matter expertise, feedback on training content, and support with developing case scenarios Supplemental Appendix 1; 3) typical learners (clinicians) through one-on-one sessions to gather target audience feedback; and 4) a one-time patient panel of Kaiser Permanente members of diverse race, ethnicity, gender, age, and parental status who gave feedback on how their primary care providers should engage with patients regarding social health data and care adjustment. The core team recruited advisory committee members based on social health integration expertise, maximizing representation across Kaiser Permanente regions and roles. Patients for the advisory panel were identified on prior engagement with the health care system to address a social need. Because of COVID-19-related restrictions and the goal of ensuring access for participants from multiple regions, all sessions took place virtually Microsoft Teams. Data are available upon request. Readers may contact the corresponding author to request underlying data.
Table 2:
Description of codesign groups
| Group | Number of participants | Organizational role | Areas of expertise | Contribution to codesign |
|---|---|---|---|---|
| Core design team | 7 | Clinicians, researchers, instructional designers | Patient care, instructional content and design, social health, implementation, research | Identified and recruited advisory committee members; solicited and incorporated input from all groups; ensured evidence-based content; drafted content and embedded training activities |
| Advisory committee | 15 | Clinicians, researchers | Patient care, social health, care adjustment | Codeveloped objectives, codesigned case studies; provided feedback on all aspects of the training (eg, content, format, activities) at multiple stages of development |
| Typical learners | 4 | Clinicians | Patient care, engaging with patients | Provided feedback on early versions of the training so the core design team could make further enhancements before finalizing the course for distribution |
| Patient panel | 5 | Patients | Lived experience | Diverse panel (by race, ethnicity, gender, age, parental status) with members who received social health care through Kaiser Permanente and shared how clinicians should engage with patients about social health and social needs |
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User-Centered Design
The authors employed user-centered design to codevelop the online CME in partnership with the identified stakeholders.18 User-centered design is a rigorous approach that focuses on empathy and the emotions, needs, and desires of impacted stakeholders.19 The approach to user-centered design used in this study followed the discover, design/build, and test framework (Figure 1),20 a three-phase process that allows for iterative codevelopment of innovation. This article presents the findings from the first 2 phases (discover and design/build). In the discover phase, the authors collaborated with the advisory committee and patient panel to identify clinicians’ and patients’ priorities and perspectives regarding social health integration and adjustment. For the design and build stages, the authors worked with the core team, advisory committee, instructional designers, and typical learners to synthesize learnings from the discover phase, develop content to address knowledge gaps and promote skill building, and test and refine these concepts with end users. The results were incorporated into the final course, called Addressing Social Health in Medicine.20
Figure 1:
Discover, design/build, and test framework applied to the development of an online continuing medical education course. CME = continuing medical education. From "Addressing Social Health in Medicine" learning activity, April 2022. Reproduced with permission from Kaiser Permanente Enterprise Learning, Oakland, CA.
Online CME platform
The authors partnered with Kaiser Permanente Enterprise Learning, an internal instructional design service, on the online CME. Core team members met weekly with Kaiser Permanente Enterprise Learning to develop objectives, provide input on training content, and review progress. National-level Kaiser Permanente social health executives (vice presidents of social health), the advisory committee, and core team members reviewed preliminary versions of the clinician training 3 times, providing detailed feedback for revisions at each step.
Thematic Analysis
Field notes and video recordings were collected for all codesign sessions. The authors conducted thematic analyses of these artifacts throughout the codevelopment process to inform the design and build stages. Thematic analyses were led by two of the authors (MCB and AP), who continually reviewed field notes and recordings to abstract key ideas and identify emergent themes, particularly adjustment barriers. These emergent themes were shared with the research team and advisory committee for discussion, reflection, and refinement, both as part of the design and build stages and for the overall analysis of the user-centered design process. Key findings were incorporated into online CME content and refined during the design and build stages. The core team agreed on the final set of themes included in this article.
IRB Approval
This quality improvement work did not undergo IRB review. The team developed a novel, care adjustment-focused continuing medical education (CME) course. This activity did not include being engaged in human subjects research.
Results
Barriers
Barrier 1. Differing regional practices
At the start of the codesign process, only of the some regions had widely implemented social health screening, community health workers on primary care teams, and/or assistance programs fully integrated with community-based organizations’ information technology systems (closed-loop referral). The advisory committee recommended that the CME be tailored to regional contexts to maximize relevance and utility. The original intention was to create one training with multiple “paths” for clinicians to choose depending on their region. However, this approach was not feasible within the learning platform. Furthermore, region-specific content would become rapidly outdated as organizational social health integration continued to develop.
Barrier 2. Lack of evidence for specific adjustments
The lack of specific, evidence-based adjustments to incorporate into the training was another barrier surfaced by the advisory committee and core team members.14,21 Given the lack of empirically driven adjustments and evidence-based metrics, the authors asked the learners (clinicians) how best to provide concrete guidance on adjustment in the online CME. They suggested including an overall adjustment framework using real-world, interactive case studies that demonstrated examples of adjusting care based on patients’ social circ*mstances (Figure 2).
Figure 2:
Overview of range of strategies for integrating social care into health care delivery from Addressing Social Health in Medicine. From "Addressing Social Health in Medicine" learning activity, April 2022. Reproduced with permission from Kaiser Permanente Enterprise Learning, Oakland, CA.
Barrier 3. Adjustment as substandard care
During the codesign of the case studies, clinicians expressed concerns about adjustment resulting in substandard care, violating standard best practices. For instance, during the development of a case study about a patient who could not afford glucose test strips, some clinicians worried that reducing the frequency of blood glucose testing was substandard, inadequate care; others felt the approach was appropriate and realistic, reflecting the patients’ social circ*mstances. These adjustments were particularly concerning when not paired with assistance, for example, financial aid for purchasing test strips.
Barrier 4. Patient and clinician discordance on the clinician role
Both patients and primary care providers agreed that addressing patients’ social health is an essential component of whole-person health care and an important driver of physical and mental health. More specifically, they agreed that identifying and addressing social needs and adjusting care based on social risks are important components of providing care and ensuring that patients can follow through on care plans. However, the groups held different perspectives about clinicians’ role in this process.
Many primary care providers in the advisory committee felt social care was primarily the purview of other team members, for example, social workers or lay health workers. This was partly due to perspectives that social care is, in principle, about screening for social needs and providing referrals to community-based resources (awareness and assistance), not adjustment. In contrast, patients wanted and expected their primary care providers to, at minimum, acknowledge their social circ*mstances. They also wanted their primary care providers to incorporate disclosed social health information in care planning. Patients were clear that planning care around social risks was realistic and adapting care based on social risk would help them take care of their physical health. Patients wanted to know their care options and the trade-offs of different approaches and to work with their primary care provider to select the best approach for their circ*mstances.
From the patient perspective, in the absence of discussion and collaboration (with possible adjustment), they made difficult health care decisions alone, without completely understanding the trade-offs. Without conversations and adjustments, some said they must choose between either adhering to care plans and sacrificing an aspect of their social health (eg, paying rent or buying healthy food) or not adhering to their plan and sacrificing physical health.
Clinicians expressed concerns about extra time to work with patients to adjust care, despite being presented with evidence that contextualized care saves time in the long run and improves patient outcomes.11–13 In contrast, patients felt that having their primary care providers acknowledge their social risks was worth the time during a visit. Patients recognized the time constraints on their primary care providers and were comfortable working with other care team members on assistance. In these circ*mstances, patients preferred for their primary care providers to tell them they did not have time to address risks directly but would connect them to a care team member who could, rather than ignoring their social risks entirely.
Solutions
Based on this input from clinicians and patients, the development effort shifted from online CME focused solely on care adjustment to broader education on a range of strategies for integrating social care into health care delivery (Figure 2). The final online CME course contains 3 sections: Part 1 provides an introduction to social health integration and why it is critical for overall health, including how to respond to patients’ social risks and needs by adjusting care plans and connecting to resources; part 2 provides an overview of organizational social health integration strategy; and part 3 presents the interactive case studies. The authors also developed “tip sheets” to accompany the online CME course and reinforce key concepts from the training (Supplementary Appendix 1–4).
To respond to differing regional practices (barrier 1), the online CME provides an overview of Kaiser Permanente’s social health framework with examples of social integration at the time of development. The authors supplemented this overall framework with an activity for clinicians to learn how social health integration is operationalized in their region with resources to learn more. Examples of questions clinicians respond to during the activity include “What screening tools are available in my region?” and “Who on the care team is in the best position to adapt care plans to accommodate social risks?”
In response to the lack of evidence about specific adjustments (barrier 2), ethical concerns about substandard care (barrier 3), and patient–clinician discordance, the authors drew from work on contextualized care11–13 and shared decision making to provide a general four-step framework for addressing social risks22,23 (Figures 3 and 4). The steps are as follows: 1) Pay attention (Supplemental Appendix 3) to clues and red flags about a patient’s social risks. 2) Ask questions to find out more. 3) Make sure that you understand the patient’s social circ*mstances and how these circ*mstances impact the patient’s ability to follow care plans. 4) Work with the patient to adapt their care plan based on their social risks. To complement this broader framework and reinforce the benefits of care adjustment, the authors incorporated patient perspectives and available evidence (for example, that adjusting care ultimately saves time) throughout the online CME.
Figure 3:
Scenario from Addressing Social Health in Medicine depicting four-step framework for addressing patients’ social risks. From "Addressing Social Health in Medicine" learning activity, April 2022. Reproduced with permission from Kaiser Permanente Enterprise Learning, Oakland, CA.
Figure 4:
Interactive element from Addressing Social Health in Medicine debunking provider assumptions that discussing and addressing social health with patients takes more time. Learners can select Yes or No; in both cases, the same text in the blue box appears. From "Addressing Social Health in Medicine" learning activity, April 2022. Reproduced with permission from Kaiser Permanente Enterprise Learning, Oakland, CA.
The final section of the training reinforces this framework with 3 interactive case studies codeveloped with the clinicians on the advisory panel based on the care adjustment situations they experienced (Figure 5). The final course, Addressing Social Health in Medicine,20 launched in April 2022 for 1.0 CME credit.
Figure 5:
Care adjustment scenario from Addressing Social Health in Medicine. Primary care providers are asked to select each option to learn why each one is an appropriate adjustment and assistance approach to address Margaret’s social risks. From "Addressing Social Health in Medicine" learning activity, April 2022. Reproduced with permission from Kaiser Permanente Enterprise Learning, Oakland, CA.
Discussion
The process used in this work identified a number of barriers to social risk adjustment, including a varied and rapidly shifting social health integration landscape across Kaiser Permanente, concerns about adjustment as substandard care, and differences in patient and clinician perspectives on the role of primary care providers. The authors found that codesigning the training and implementation of social risk–informed care with patients and care team members effectively identified these critical barriers. It was especially useful for areas such as adjustment that lack a robust evidence base. The authors also believe that the prioritization of multiple codesign participants from diverse backgrounds and experiences helped surface barriers that otherwise would have missed.
The authors are currently evaluating the online CME course using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework24 and Kirkpatrick’s evaluation model as applied to medical education.25 These models prioritize theoretically and contextually appropriate outcomes spanning effectiveness and implementation and can provide insights into the effectiveness of the training on provider knowledge, self-efficacy, and changes in adjustment practices.
Health care systems are just starting to integrate social health and address patients’ social needs. The effective implementation of social health integration will require ongoing dialogue among systems, primary care providers, and patients; inclusion of patient stories; and generation of new evidence to inform policy and practice. In particular, the intersection of care adjustment and evidence-based standards of care raised ethical issues with clinicians during the codesign sessions. Additional research on real-world care adjustment must build a more robust evidence base regarding effective adjustment implementation strategies, the relationship between social risk adjustment and health outcomes, and the relationships and pathways among adjustment, assistance, and health.
Trainings such as the online CME developed in this work are an important first step for making social health integration part of standard care but should be one element in a multipronged approach. Education is necessary but not sufficient for supporting implementation and changing practices.26 Based on their experience, the authors believe that more nuanced, active, flexible implementation strategies such as audit and feedback are likely to be important complementary activities for adjustment and social health integration. This conjecture is echoed in the broader provider behavior-change literature, which finds that more complex intervention approaches are more likely to succeed.26 Audit and feedback cycles, or at a minimum, ongoing consultations and check-ins, are critical to help clinicians develop knowledge about a new practice and apply it to their (Supplemental Appendix 3) patient encounters.27
System-level implementation strategies must accompany individual clinician approaches whenever possible. The range of possible strategies includes 1) updating medical school curricula or other education resources for primary care providers to emphasize the impact of social determinants on physical health and train clinicians in social risk adjustment, 2) increasing clinician visit lengths to ensure time for whole-person care, 3) building social risk adjustment into clinical decision support tools, 4) including lay health workers on care teams to offload resource connection (assistance) from primary care providers, and 5) prioritizing meaningful collaboration with community-based organizations and resources.
Conclusions
The experience codeveloping an online CME for primary care providers described in this article demonstrates that codesign is valuable for generating relevant, meaningful content reflective of provider and patient experiences, particularly when packaged to acknowledge and challenge concerns that could undermine implementation. Although one-time education programs are important for communicating high-level concepts and frameworks, changing provider behavior requires more active and ongoing clinic-based implementation strategies (Supplemental Appendix 4). Furthermore, health care organizations likely need to make system-level changes to fully realize the vision and impact of social health integration on patient health and health equity.
Supplementary Material
Table S1
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Table S2
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Table S3
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Table S4
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Acknowledgments
The authors acknowledge the instructional design expertise of Julie E. Hymes and Derek Ecklund from Kaiser Permanente Enterprise Learning. They also recognize the contributions of Amy Allen, Kaiser Permanente Washington; Caitlin Dorsey, Kaiser Permanente Washington Health Research Institute; Lauren Galpin, MD, Colorado Permanente Medical Group; Laura Gottlieb, MD, MPH, Social Interventions Research and Evaluation Network; Jennifer Kelloff, MD, Colorado Permanente Medical Group; Maggie Marshall, LCSW, Kaiser Permanente Medical Center Sacramento; Courtney Kraus, MSPH, Kaiser Permanente Colorado Institute for Health Research; Anand Shah, MD, MS, Kaiser Permanente Office of Community Health; Gina Sucato, MD, MPH, Washington Permanente Medical Group; Kumara Raja Sundar, MD, Washington Permanente Medical Group; Nancy Trego, NP, Kaiser Permanente Northern California; and Chris Tachibana, PhD, Kaiser Permanente Washington Health Research Institute.
Footnotes
Author Contributions: All authors participated in the conceptualization, critical review, drafting, and submission of the final manuscript, as well as the design and implementation of the online CME.
Conflicts of Interest: None declared
Funding: This work was supported by Kaiser Permanente National Community Health.
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