Nirav Shah, MD, MPH, is a Senior Vice President and Chief Operating Officer for Clinical Operations at Kaiser Permanente, Southern California and an Academy Fellows Ambassador.
So often, it’s the simple things that make a great difference in life. That’s one of the first lessons we learned at Kaiser Permanente when we embarked on a journey to expand our comprehensive support to members with the most substantial medical needs.
Working with one of those patients, Daniel* showed us just how important it is to focus on the things people value most when trying to protect their health. Daniel loved getting out to walk in his neighborhood with his dogs. At 64, he had many health challenges, but this activity, along with his community-based social support network, was his lifeline.
In terms of his health, we knew that Daniel would likely need ongoing care services and regularly-scheduled visits in the coming year. However, once we enrolled him in our expanded Health Leads pilot program, we discovered a threat to his well-being that would not have been identified during a usual doctor’s visit.
Daniel had begun to fall when leaving his building for his daily walk. He only had to negotiate two stairs, but it was enough to destabilize his gait. This led to an even greater fear that he would have to move. He told us he was “terrified” of having to leave the neighborhood and lose touch with the people closest to him. Our call center team stepped up to help. After they reached out to Daniel’s tenant organization, the building manager responded quickly and added a hand rail to the staircase.
Once he was able to steady himself, Daniel could continue the walks that gave him joy, and he was also very relieved to know that he could now remain in the social network that sustained him.
Whole Patient Care
The project that helped Daniel is a partnership with Health Leads, an organization that “addresses all patients’ basic resource needs as a standard part of quality care.” Keeping in mind that 60 percent of what keeps us healthy comes from social, environmental and behavioral factors, while just 10 percent is related to clinical care, we are addressing the broader determinants of health by identifying the unmet social needs of our “high-utilizer” patients, like Daniel.
These patients are part of a very different type of 1 percent—the approximately 40,000 of our 4 million Southern California members who account for 23 percent of our health care spending. Nationwide—5 percent of high-utilizer patients account for more than half of our health care expenditures.
Aside from the financial impact, the toll on the quality of these patient’s lives is considerable. They are bounced around medical systems, with some being called by no less than three case managers while attempting to get care. Clinicians may want to help them, but they seldom have the training or resources to offer social services.
Our research shows that contacting these patients through a call center is a scalable, low-cost way to reach them and learn about their social needs. Through the pilot, we called 867 members and 69 percent talked with our team.
They are asked questions that include:
l. Within the past 12 months, “the food I bought just didn’t last, and I did not have the money to get more.”
– 32 percent said “yes”
2. Do you worry about having a safe place to live or being homeless?
– 35 percent said “yes.”
3. Do you have difficulty arranging for transportation to or from your medical appointments?
– 26 percent said “yes”
4. Do you need help paying your utility bills?
– 23 percent said “yes.”
Overall, 78 percent of screened members had at least one unmet social need and 74 percent welcomed help—they agreed to enroll in the Kaiser Permanente Health Leads program and receive follow-up calls every few weeks until problems were resolved. For assistance, they would be linked with existing resources such as food banks, tenant’s rights’ groups or financial assistance organizations.
Seeing Cities as an Opportunity
This new approach offers considerable promise, especially in urban environments because cities are most often rich with community-based organizations that are well-positioned and eager to bridge the gaps between clinical care and the social resources that support health.
Add our greatly enhanced ability to gather and use data to identify patients in need, as the Academy does through research based in its Institute for Urban health, and it’s easy to see that we have an unprecedented opportunity to improve health, wellness and life for millions of people.
We can also see that by helping patients get what they need—an enhanced ability to maintain purpose, meaning and joy in life—we may get what we need in health care—a chance to greatly lower costs and improve health care outcomes for the patients who depend on us the most.
*The patient’s name has been changed to protect privacy.
Acknowledgment: Artair Rogers, MS, Adam Sharp, MD, and Adam Schickedanz, MD, helped to lead this work at Kaiser Permanente, Southern California. We also thank Rebecca Onie, Alexandra Quinn, and Kelly Hall at Health Leads for their insightful guidance
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