Kaiser to launch social care network

Kaiser Permanente will soon launch a new care network that connects the system's more than 12 million members to community services that address their social needs.

The Thrive Local initiative will be integrated into Kaiser's electronic health record, and will be rolled out regionally this summer, though the first location hasn't been announced yet. Over the next three years, the health system will make it available throughout the entire system.

The program will allow healthcare providers and caregivers to connect patients with community resources that can help them address needs such as food insecurity or housing instability from an array of not-for-profit, public and private social services.

Kaiser Chairman and CEO Bernard Tyson said the initiative was the next step in the system's continued mission to create a positive impact on the health of both Kaiser members and their communities.

"This is now leveraging technology, leveraging community resources and leveraging the expertise of Kaiser Permanente both in terms of our medical expertise and our community health expertise, but also our expertise in scaling up and connecting dots and maximizing resources," Tyson said. "So, this is a great opportunity for us to bring all of this together in the best interest of our members and our communities."

Tyson said one of the challenges will involve identifying each community's unique set of resources and issues when it comes to addressing social needs.

Dr. Bechara Choucair, chief community health officer at Kaiser Permanente, said Thrive Local will build upon the work Kaiser has already done across its network to identify needs through its patient screening for social health determinants. He said that work has helped Kaiser to partner with a number of community organizations that will be included within its new social care network.

"We really have to understand the supply and demand when it comes to social health," Choucair said. "And we know that this is going to be a long process and we need to do it carefully and thoughtfully community by community."

Kaiser also plans to make Thrive Local's network of resources available to community-based organizations to help them reach out to individuals in need who are not Kaiser members.

The network will track community partner referrals and service outcomes to measure the degree to which participants' needs are met. Data will be collected and reviewed to regularly to make improvements when needed.

Kaiser is partnering with Unite Us, a social care coordination platform, to build and operate the network.

A number of hospitals and health systems in recent years have begun to incorporate patients' social needs within their EHR systems to aid clinicians in identifying the root cause of health problems. Some have modified their systems to help connect their patients to community resources.

But Kaiser's plan would be by far the largest initiative of its kind, potentially reaching more than 68 million people throughout the country.

"To address total health, we, as physicians, need systems and networks that address our patients' social needs," said Dr. Imelda Dacones, president and CEO of Northwest Permanente. "Healthcare in this country must continue to evolve from acute episodic care to an integrated coordinated system focused on prevention and coordinated care management."

According to Kaiser, nearly one-third of its members with the greatest medical challenges are dealing with food insecurity, while 23% have concerns about housing stability.

The initiative marks Kaiser's latest effort to address social determinants of health. In January, the system announced it was investing more than $100 million in a multiyear initiative to address homelessness in the Oakland, Calif., area and across eight states and the District of Columbia, where the system operates.

In March, Kaiser announced it was investing $3 million over the next three years toward ending chronic homelessness in 15 of its patient communities by partnering with New York-based not-for-profit Community Solutions on its Built for Zero initiative. The national program helps community stakeholders to develop tools to collect real-time data on homelessness.

Tyson said Kaiser will look to partner with other healthcare providers, who will be able to access the network. He said he hopes it will lead to building a robust infrastructure to address social needs.

"We see it as being part of a broader umbrella that other resources will be tapping into and building comprehensive systems to take care of these needs," he said.