This case study is part of the CIN series Stories from the Field: Social Needs Screening and Referral Models.¹ Its resources include the tools Kaiser Permanente Northwest used to take action across its systems.

Table of Contents

• Organization Overview
• Social Needs Screening and Referrals Workflow
• Key Staff
• Leveraging Technology
• Results and Next Steps
• KPNW’s Five Lessons for Social Needs Screening and Referrals Projects

How does a large, integrated health system respond when a patient’s major barrier to living a healthy lifestyle isn’t accessing medicine, but obtaining a refrigerator in which to store that medicine?

Kaiser Permanente Northwest (KPNW) has a long history of conducting research aimed at better understanding how to improve medical care and quality of life. In doing this research, the organization realized that many of the barriers to good health reside outside of the medical system — for example, access to housing, nutritious food, and a safe environment.

In early 2016, KPNW began to build and implement a standardized model to assess and address patients’ social needs. A multidisciplinary team of operations, clinical, and research staff developed and refined two important resources:

1. A standard tool for collecting and documenting social needs data
2. A local model for referring patients to the appropriate social service or community organization

This case study will review lessons and best practices from KPNW’s Phase I Social Needs Screening and Referrals Pilot, with a focus on operations management, workflows, and the technical tools that have been implemented to successfully do this work.

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Organization Overview

KPNW is an integrated health care delivery system that provides care to more than 600,000 members in Oregon and Southwest Washington through its 34 medical offices and two hospitals.

Organization	Kaiser Permanente Northwest
Project	Standardize social needs screening and referral process: Phase I: Pilot screening and referrals model at KPNW over two-year period Phase II: Distribute KPNW’s social screening and referral model to all KPNW locations across the US, including a new social service resource locator that will allow for bidirectional communication between KPNW and community organizations
Implementation Status	Phase I is complete (March 2016–March 2018) Phase II is underway, with deployment of social service resource locator expected in Q2 2019 2019 marks the third year of KPNW’s social determinants of health work
Tools and Methods Tested	Your Current Life Situation questionnaire (homegrown social screening tool); ICD-10 Z Codes; KPNW/Epic EHR SmartSets (used for tracking community/social referrals)
Funding Source(s)	This work is mainly funded through KPNW health plan income

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Your Current Life Situation: A Five-Minute Patient Assessment

KPNW determined that the first step in addressing patients’ social needs was to document and measure those needs in a standardized way. In conjunction with the Care Management Institute, KPNW created a social needs screening tool called Your Current Life Situation (YCLS). The YCLS questionnaire consists of nine core questions related to housing, finances, food insecurity, transportation, activities of daily living, and stress. There are an additional 21 questions and follow-up items that a patient may be asked if they screen positively for a social need.

The Phase I pilot focused on proactively screening three distinct patient populations:

1. Complex care/rising risk patients
2. Emergency department (ED) and/or hospitalized patients
3. New KPNW members

Additionally, when providers discovered a patient had an unmet social need (such as homelessness) during a routine visit, they were able to refer the patient to a patient navigator for a full YCLS assessment and appropriate community referrals.

After completing the YCLS questionnaire, patients were asked if they would like assistance in any social domain before being referred to a patient navigator. The initial questionnaire takes about five minutes to complete. A positive response to any question will trigger a conversation about community resources, which takes much longer than the screening itself.

The assessment is repeated at a frequency dependent on the patient’s level of need or based on the pilot population to which they belong. Staff members aim to screen patients in the Complex Care Program once every six months, and they work to screen the two other pilot populations annually.

The actual questionnaire is really simple and something you can complete pretty quickly… But the resource conversation that stems from whatever social needs were identified — that is where the “meat” of the conversation is and can be a much longer discussion.

—KPNW patient navigator

Social Needs Screening and Referrals Workflow

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Key Staff

Patient navigators play an integral role in KPNW’s social needs screening and referrals model. They are nonclinical members of the care team who help connect patients to community and social service resources. All navigators are required to complete the necessary training to work as certified application counselors so they may assist patients in applying for health insurance coverage, such as Medicaid. Many of KPNW’s patient navigators are also certified community health workers.

It has been important to communicate to staff that this [screening] isn’t just a “new thing” we are going to implement. This is about how we interact with and treat people, letting patients know that we care about them, and engaging in a conversation rather than simply checking a box.

—KPNW department administrator

The image below provides an overview of the major responsibilities associated with this role, the typical employee background, and the training each navigator is required to complete. Over the first two years of this project, 30 patient navigators screened over 11,000 patients for social needs using the YCLS screening tool.

Leveraging Technology to Facilitate Social Needs Screening and Referrals

KPNW has worked with its electronic health record (EHR) vendor, Epic, to develop a set of three social determinants of health (SDH) SmartSets to help facilitate electronic documentation of social needs screening and referrals. A SmartSet is a set of provider prompts that helps guide treatment. It can include a combination of common orders, tests, and diagnoses, and can autopopulate text in the progress note.

• SDH SmartSet: Once a patient completes the YCLS assessment (either electronically via tablet at the hospital, or with the patient navigator in-person or via telephone), the navigator ensures the patient’s responses are entered into the structured fields in the SDH SmartSet in the EHR and assigned the appropriate ICD-10 Z code. Analysts can easily extract this data from the EHR for quality improvement or research projects. Although KPNW has begun coding for social needs work, it is not yet able to bill for the screening; this work is currently supported through health plan funding.
• Community Resource Referral SmartSet: Patient navigators maintain and update the Community Resource Referral SmartSet’s list of over 200 internal and external resources that address social needs. Internal resources include Medicaid application assistance and financial health advising, while external resources include programs such as local food banks and housing providers. The patient’s responses to the YCLS autogenerate recommendations for community resource referrals. The navigator will either provide the referral information to the patient so the patient can contact the community resource directly, or they will contact the community organization to schedule an appointment on behalf of the patient.
• SDH Community Resource Summary Progress Notes SmartSet: Once a referral has been made, the referral data is tracked via the SDH Community Resource Summary Progress Notes SmartSet. Referral data include referral status (e.g., did the patient meet with the community organization?), progress (e.g., did the patient successfully get on a housing list?), and patient preference (e.g., is this patient open to receiving similar types of referrals in the future? Did they find the community organization helpful?). Due to resource limitations, patient navigators are unable to follow up with all patients. Instead, they focus their efforts on following up with patients who have the most complex needs. Navigators follow up by phone or during the patient’s subsequent primary care visit and document the status of the community referral by inputting this data into the SmartSet. In the future, KPNW plans to implement a more streamlined electronic process for completing these closed-loop referrals with community organizations.

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Results and Next Steps

From 2016 to 2018, KPNW’s team made over 18,000 referrals to community-based organizations. The three most commonly identified needs were medical, food, and transportation support.

Phase II of KPNW’s social needs screening and referral work will include the uptake and distribution of Phase I tools across KPNW sites, including:

• YCLS questionnaire
• SDH SmartSet
• ICD-10 Z codes

KPNW is also in the process of identifying a vendor to develop and aid in implementation of a new nationwide Social Service Resource Locator (SSRL). The SSRL will serve as an electronic community resource directory and referral system and will provide a standard way to connect patients to social service resources across Kaiser regions. It will facilitate closed-loop referrals by offering bidirectional communication between KPNW and participating community organizations.

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KPNW’s Five Lessons for Social Needs Screening and Referrals Projects

We don’t want to provide a resource to a patient that they don’t qualify for. The patient is unlikely to engage with us again if this happens, or they’ll assume, “Since I don’t qualify for this program, I must not qualify for any programs.”

—KPNW patient navigator

For those preparing to undertake a new social needs screening and referral project, the KPNW team shares the following lessons.

1. Leadership buy-in: Prior to implementing a new SDH project, it was important to get leadership buy-in on building a trauma-informed SDH program. A trauma-informed SDH program is one in which:
   • Assessing and addressing SDH is considered valid and essential for improving patient health
   • Staff acknowledge that many patients affected by social inequities and structural violence have experienced some level of trauma and require a respectful trauma-informed approach
2. Staff time and expectations: KPNW recognized in the beginning of its Phase I SDH pilot that in order to gain staff buy-in it would need to ensure frontline staff and management had similar expectations about the project’s purpose and time commitment. Staff members were trained on how to efficiently and effectively assess and address patients’ social needs. It was important to establish the appropriate length of time needed to ask SDH questions (so staff would not rush through the assessment and referral process), how to do so in a culturally competent manner, and the resulting workflows when a patient screened positive for a social need and required a referral to an external organization.
3. Awareness of community resources and enrollment criteria: In order to refer patients to the appropriate social service organization, staff need to have an awareness of which organizations are available and, perhaps even more importantly, the criteria for accessing each organization’s resources.
4. Awareness of resources for staff: In addition to understanding what resources are available for patients, KPNW found it important to promote the resources available for patient navigators and other staff working on SDH programs themselves. This type of work can easily lead to burnout, so leadership must ensure staff not only feel valued and supported, but that they have adequate access to mental health and addiction resources if needed.
5. Closed-loop referrals. Although patient navigators had the capacity to document SDH in the SmartSet, they had limited time to follow up with patients and track referral status. KPNW is hoping this issue will be remedied when it rolls out its SSRL later this year, giving community organizations the ability to electronically close the loop when a patient completes their referral.

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1. Kaiser Permanente Northwest conducted this work on its own and without any funding or support from CIN or CHCF.