Abstract
OBJECTIVES: In the US, there is growing recognition that social factors (eg, financial hardship, food insecurity, housing instability) influence individual and population health. This has led to increased efforts to address these social determinants of health (SDH) within the delivery system. Yet, limited information exists about the strategies health care systems employ to identify and address SDH. Kaiser Permanente Northwest (KPNW) is an integrated health care delivery system that has implemented a comprehensive approach toward addressing its patients’ SDH. This article describes the tools and processes used at KPNW for identifying and addressing SDH. METHODS: Tools included use of electronic health record-based data elements, International Classification of Diseases, Tenth Revision social diagnostic codes (Z codes), and the development of novel workflows via nonclinical patient navigators to address patients’ SDH through community resource referrals. Between March 31, 2016, and March 25, 2018, KPNW patient navigators screened patients with SDH. RESULTS: Patient navigators screened 11,273 patients with SDH, identifying and documenting 47,911 SDH in the electronic health record. During the same 2-year period, 18,284 community resource referrals were made for 7494 patients. CONCLUSION: The novel electronic health record-based tools developed by KPNW have led to standardized, measurable, and actionable SDH data being used to tailor and target specific resources to meet the identified needs of our patients. By disseminating information about these efforts at KPNW, we aim to help build an evidence basis of different approaches for addressing SDH within the health care system as well as defining opportunities to improve care efficiency for patients with SDH.