This brief is part of our Research Roundups series.
Social needs like safe housing, financial wellness, and access to nutritious food have profound short and long-term impacts on health. These needs are driven by upstream social determinants of health, which are estimated to play a greater role in shaping health outcomes than genetics or health care.1,2 The health sector recognizes that addressing social needs can improve health for all patients and reduce health disparities, so many health systems and plans are collaborating with community-based organizations to connect patients with resources like healthy food and reliable transportation.
National research shows over 80% of hospitals collect data on their patients’ social needs and 65% of hospitals use those data for referrals to social service organizations, though many providers note there are administrative and staffing challenges to coordinating care.3,4 There are also federal and state policies that aim to support social health, such as providing reimbursement for community health worker interventions.
As health systems seek to act on social needs to address root causes of health problems, researchers and policymakers are wondering how best to measure the impact of social needs interventions and prioritize the most effective strategies. Kaiser Permanente has been investing in and expanding both our research on social needs and strategies for addressing social determinants of health. Our staff are trained to discuss social needs with patients in culturally sensitive ways and refer them to our Community Support Hub, which helps patients and their families access important resources like food and housing assistance, career skills training, and financial literacy programs.
Kaiser Permanente is also a thought leader in this field via the Social Needs Network for Evaluation and Translation (SONNET), which convenes researchers and leaders to build capacity for social health research and aims to identify best practices for social health interventions.
Kaiser Permanente researchers from SONNET recently published a study that explores questions of interest to policy audiences:
- What information do researchers and clinicians addressing social health feel they need to advance their work?
- What specific social health research questions are most important to answer right now?
2023 article in American Journal of Preventive Medicine
Kaiser Permanente SONNET researchers used a stakeholder-driven process to identify social health research opportunities and prioritize those opportunities by their impact and urgency. They asked 746 stakeholders, including clinicians, researchers, and program managers, what they wished they knew more about to advance their work in social health. The researchers synthesized the stakeholders’ responses and translated them into research questions that could be rated in order to identify the most important topics for social health research.
Stakeholders submitted 515 statements that spanned a range of categories, such as how and when to engage patients about their social needs, best approaches to social needs interventions, and identifying patients most in need of social health supports. These statements were synthesized into 59 distinct research questions, which were then rated on impact and priority by a smaller committee of 16 experts within SONNET. The researchers used those ratings to calculate mean impact and priority scores, then ranked the research questions by their combined score.
The top research questions centered on 1) which social needs health systems should prioritize addressing first when treating patients, 2) the health and financial impacts of health system-supported referrals to community-based social health resources, and 3) the most effective ways to measure changes in social health. The other highly rated questions varied in their focus, ranging from ways to resolve social needs that result in avoidable hospitalization to patient-centered approaches for health systems to support social health. This suggests much of the foundational research on how health systems can best address social needs remains to be done.
Although there is substantial data pointing to the impact of social needs on health outcomes, the evidence base for effective social health interventions is still emerging. This is in part due to the interconnectedness of social needs, as well as the broad variation in social health interventions and lack of coordination across health systems, health plans, social services, and researchers.
In addition to shaping SONNET’s work, Kaiser Permanente also supported a small grants program for researchers to develop studies aligned with the priority research questions, demonstrating how this process can also translate stakeholder input into action.
Policy opportunities
No single study can suggest the full range of policy needs and opportunities. Based on existing research and internal discussions among Kaiser Permanente researchers and social health leaders, we recommend several avenues for better understanding opportunities to address social health and for implementing evidence-based interventions:
- Support policies that enable payers and providers to collect and appropriately share social health data.
- Collect standardized, actionable data on social needs: Encourage states, accrediting bodies, and others to work together to standardize social health metrics and data collection in support of future interoperability. Encourage payers and providers to regularly collect these data, which should include both individual and community-level social needs.
- Create robust data infrastructure that facilitates communication and referrals: Create and strengthen data linkages between payers, providers, and community and social services, facilitating communication and referrals for payers and medical service providers. In particular, invest in modernizing the information technology infrastructure used by health and human service programs to support interoperability.
- Develop novel approaches to financing and care delivery that allow payers and providers to adequately address patients’ social needs.
- Remove policy barriers to addressing social health: Reduce or eliminate regulatory barriers that prevent payers and providers from addressing unmet social needs that directly affect health outcomes. For example, anti-kickback and beneficiary inducement rules can discourage health plans and providers from offering food, transportation, or housing-related supports – even when these services are clinically appropriate and improve care adherence – because of concerns they could be construed as improper incentives. Similarly, health plan bidding and benefit design rules often require social health services to be included as supplemental benefits with additional costs, limiting flexibility and discouraging investment in cost-effective interventions that could reduce downstream medical spending.
- Incorporate social needs into payment models and care eligibility decisions: Develop innovative payment models that encourage payers and providers to enhance their service delivery models in ways that better support health-related social needs and social service organizations. For example, updating and optimizing payment codes and risk adjustment models to account for social needs, behavioral health, and related interventions would likely increase access to care and social needs resources.
- Develop data-driven interventions: Take a data-driven approach to the development of patient and population-level interventions that advance better health outcomes for all — but especially for groups who currently have the poorest outcomes — by addressing social needs. Standardized social health metrics will also enable effective evaluation and improvement of these interventions.
- Support upstream interventions to address unmet social needs, including housing, social isolation, and environmental hazards.
- Build community capacity for prevention and early intervention: Support programs and organizations focused on prevention and early intervention for social health risks, such as behavioral health and substance use. Leverage community settings, including schools, to address factors that contribute to poor mental and physical health.
- Invest in public education and communication on social health: Support the involvement of payers and providers who can serve as trusted messengers on social needs and their impact on health. Increase awareness of resources for social needs, reduce the stigma of seeking help, and ensure that individuals know they can ask their health care providers for support with accessing social health resources.
- Leverage knowledge and capabilities of health systems: Develop opportunities for payers and providers to partner with researchers, public health departments, state agencies, and safety-net organizations to build innovative approaches that integrate health care and community-based providers’ services.