TY - JOUR
AU - C. C. Lewis
AU - M. D. Pullmann
AU - C. Hsu
AU - C. Norris
AU - J. Mogk
AU - R. Pardee
AU - C. Walsh-Bailey
AU - E. Westbrook
AU - A. Lee
AU - J. Ridpath
AU - C. DeWitt
AU - A. Mahmud
AU - K. Coleman
AU - P. Lozano
A1 - 
AB - BACKGROUND: Social care integration in health systems is on the rise in the United States, particularly since the National Committee for Quality Assurance introduced screening and intervention as HEDIS metrics. These policy levers outpace empirical knowledge to guide how best to operationalize social care. This study reports results from a quality improvement initiative to implement social care in an integrated health system. METHODS: A quantitative effectiveness evaluation was conducted across 32 clinics in Kaiser Permanente Washington, which had recently embedded Community Resource Specialists (CRS) in their primary care teams and integrated a social health screener into their electronic health record. Using a pragmatic design with propensity score matched comparison group (PSC), we compared two intervention arms (both of whom completed a social health screener): (1) CRS-S who engaged in only a single CRS visit and (2) CRS-M who engaged in at least two CRS visits. Patients completed a survey shortly after their qualifying primary care encounter and approximately three months later that assessed the following domains: social health, patient experience with the care team, and health and functioning; healthcare utilization was obtained from the electronic health record. Patients from each arm were then purposefully sampled for qualitative interviews. RESULTS: Quantitative results suggest that CRS-M patients experienced exacerbated social risk severity and food insecurity over three months, but improved financial risk. For the majority of domains, no differences were observed between arms, though CRS-M demonstrated poorer coping over time whereas PSC patients showed higher use of instrumental and emotional support coping strategies. CRS-M reported worse health and need for more help with activities of daily living, but improvements in trust in their care team. Qualitative results showcased, by design, the positive potential impact of working with a CRS across all domains of interest, especially social and mental health. CONCLUSION: This quality improvement evaluation of social care integration using the CRS illustrates a potential pathway for activating social support and healthcare relationships in primary care, but more rigorous designs and longer-term follow up are needed to explore if this pathway leads to improvements in patient or population health and healthcare utilization.
AD - Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA, 98101, USA.; , Seattle, WA, USA.; Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, 625 N. Michigan Av, Chicago, IL, 60611, USA.; Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA, 98101, USA. emily.o.westbrook@kp.org.; Kaiser Permanente Washington Health Plan, 2715 Naches Ave. SW, Renton, WA, 98057, USA.; Research to Practice LLC, Seattle, Washington, USA.
AN - 41174488
BT - BMC Prim Care
C5 - Education & Workforce
CP - 1
DA - Oct 31
DO - 10.1186/s12875-025-02922-x
DP - NLM
ET - 20251031
IS - 1
JF - BMC Prim Care
LA - eng
N2 - BACKGROUND: Social care integration in health systems is on the rise in the United States, particularly since the National Committee for Quality Assurance introduced screening and intervention as HEDIS metrics. These policy levers outpace empirical knowledge to guide how best to operationalize social care. This study reports results from a quality improvement initiative to implement social care in an integrated health system. METHODS: A quantitative effectiveness evaluation was conducted across 32 clinics in Kaiser Permanente Washington, which had recently embedded Community Resource Specialists (CRS) in their primary care teams and integrated a social health screener into their electronic health record. Using a pragmatic design with propensity score matched comparison group (PSC), we compared two intervention arms (both of whom completed a social health screener): (1) CRS-S who engaged in only a single CRS visit and (2) CRS-M who engaged in at least two CRS visits. Patients completed a survey shortly after their qualifying primary care encounter and approximately three months later that assessed the following domains: social health, patient experience with the care team, and health and functioning; healthcare utilization was obtained from the electronic health record. Patients from each arm were then purposefully sampled for qualitative interviews. RESULTS: Quantitative results suggest that CRS-M patients experienced exacerbated social risk severity and food insecurity over three months, but improved financial risk. For the majority of domains, no differences were observed between arms, though CRS-M demonstrated poorer coping over time whereas PSC patients showed higher use of instrumental and emotional support coping strategies. CRS-M reported worse health and need for more help with activities of daily living, but improvements in trust in their care team. Qualitative results showcased, by design, the positive potential impact of working with a CRS across all domains of interest, especially social and mental health. CONCLUSION: This quality improvement evaluation of social care integration using the CRS illustrates a potential pathway for activating social support and healthcare relationships in primary care, but more rigorous designs and longer-term follow up are needed to explore if this pathway leads to improvements in patient or population health and healthcare utilization.
PY - 2025
SN - 2731-4553
SP - 330
ST - Optimizing the community resource specialist to address social needs in primary care: results from a pragmatic quality improvement evaluation
T1 - Optimizing the community resource specialist to address social needs in primary care: results from a pragmatic quality improvement evaluation
T2 - BMC Prim Care
TI - Optimizing the community resource specialist to address social needs in primary care: results from a pragmatic quality improvement evaluation
U1 - Education & Workforce
U3 - 10.1186/s12875-025-02922-x
VL - 26
VO - 2731-4553
Y1 - 2025
ER -