ACT Center findings provide insights on screening patients for social needs and helping them connect to social services
November 17, 2025
Integrating social health into primary care
ACT Center findings provide insights on screening patients for social needs and helping them connect to social services
Social health — the conditions in which people live their daily lives — is an essential part of total health. When people face social needs such as financial, housing, or food insecurity, the downstream effects on their physical and mental health can be significant. It can also contribute to disparities in health outcomes.
Kaiser Permanente Washington is one of many health care organizations nationwide exploring ways to integrate social health into routine care — through practices such as screening patients for social needs and referring them to resources within the organization or the wider community. While social health integration is a promising strategy for improving total health, little scientific evidence exists to guide important decisions about implementation.
How can health care organizations reliably identify patients who want help with social needs in a respectful and patient-centered way? And what works best to efficiently and effectively connect them to resources that can help resolve those needs? Four new papers from the ACT Center provide insights from 2 social health initiatives focused on helping answer those questions at Kaiser Permanente Washington.
A primary care-based approach to helping patients with social needs
In 2017, Kaiser Permanente Washington integrated a social health screener into their electronic health record and launched the community resource specialist (CRS) role in primary care. CRSs are members of the primary care team who work with patients who want assistance with social needs — helping them navigate needed health services and connecting them to resources in the community.
The ACT Center partnered with Kaiser Permanente Washington leaders, care providers, and patients in 2018 to implement the CRS role systemwide and to evaluate the role's impact on patients and care teams. A key goal was to optimize the CRS service by providing practice facilitation and compiling best practices and scale-up strategies into a CRS Integration Playbook.
The evaluation, which was recently published in BMC Primary Care, compared participants’ social needs after 3 months, as well as outcomes such as health and functioning, health care utilization, and patient experience with the care team. Across most of these outcomes, the findings showed no differences between patients who met with a CRS once, twice or more, or not at all. Patients who had multiple CRS encounters reported higher levels of trust in their health care providers. These patients were also less likely to report financial insecurity, but more likely to report food insecurity and more severe social risk overall.
Not surprisingly, patients with multiple CRS sessions tended to have more complex health needs — an observation that was confirmed by qualitative data collected in patient interviews. Many patients credited their CRS with helping them improve their overall health and their ability to access care and fulfill their care plan. Some even made comments such as “[The CRS] saved my life” and “I feel like I got my life back.”
“The quantitative analyses raised interesting questions about the impacts of the CRS intervention in the short term,” said the paper’s senior author Paula Lozano, MD, MPH, who codirects the ACT Center. “And our qualitative findings highlight CRSs’ potential to provide patients with support that builds a healing relationship and a pathway to needed health care services.”
Taking the next steps toward social health integration
Based on ACT Center recommendations from the CRS evaluation, Kaiser Permanente Washington opted to pilot test universal social health screening for all patients in primary care starting in 2021. The ACT Center worked alongside leaders, care teams, and patients to design and implement an approach to universal screening at 2 medical centers. After screening, patients who wanted help with social needs received a referral to 1 of 2 social health assistance programs: the local CRS service or a national call center that is part of Kaiser Permanente’s Community Support Hub.
Two recent ACT Center papers focus on how referring patients to these programs might impact health care utilization and costs — questions of great interest to health care organizations that are aiming to integrate social health while also facing resource constraints.
The first paper, published in AJPM Focus, shares results on differences in utilization between patients who were in the CRS group and those who were in the call center group. The findings showed that CRS participants had slightly more primary care and specialty care encounters over the 9-month evaluation period. Similarly, the cost analysis published in BMC Health Services Research showed slightly higher costs for CRS participants compared to call center participants. In both cases, the authors concluded that this is likely because local, clinic-based programs like the CRS service may be better integrated with care teams to provide ongoing support for patients’ health care needs and may increase patient engagement with the health system.
“Clinic-based social health support for patients with social needs can help them prioritize and access preventive care services,” said ACT Center partner Ammarah Mahmud, PhD, MPH, the lead author on both papers. “Our short time frame didn’t allow us to evaluate long-term impacts on avoidable utilization and costs related to emergency care or hospital admissions. Future research over a longer period will shed more light on these outcomes and help health systems better understand what to expect from social health integration over time.”
A closer look at the impact of social health integration on patients
Importantly, the ACT Center’s evaluation also included a qualitative analysis based on interviews with 50 patients who participated in either the CRS or call center programs. Published in BMC Health Services Research in October, these findings provide insights to help guide future social health integration efforts. Here are a few examples of key themes that emerged.
Availability and eligibility obstacles: Few patients reported successfully connecting to community resources even after working with the CRS or the call center. Many patients said that the services they needed were either not available in their community or they were not eligible for the services that exist.
“The few things that I thought I potentially was going to find were very inadequate for my needs. … You have to go through a whole application process and then get approved and then you have to be within boundaries and this and that, or [apply at] certain times and dates.”
Mismatch between patient needs and the CRS and call center services: Some patients with complex social needs were frustrated by the level of support provided, which was limited to brief conversations with a CRS or call center representative who provided information about potentially available resources. Others said they would prefer that the health system offer social health services more directly or take action to reduce their health care expenses.
“What would have been helpful would be things that people really need, like food, their water bill, like their gas bill, their electricity bill, help with their roof. When you’re living off nothing, there’s no way you can save anything to be able to pay for that.”
Regardless of resource referrals, emotional support is meaningful: Many patients who did not get connected to resources still found working with the CRS or the call center to be valuable. They especially appreciated the holistic approach to care and the knowledge that they can call someone if they need help. Several expressed that this deepened their appreciation for Kaiser Permanente and showed that the organization cared about them as a whole person.
“Even though I didn’t necessarily think I was going to get any assistance … I was interested that it was an option and that Kaiser cared enough to have someone who was a resource specialist who would reach out and work personally with families.”
Lead author and ACT Center partner Ariel Singer, MPH, noted the importance of this benefit despite the small number of patients who were successfully connected to social services. “Even though the need for services is greater than the supply, many patients value emotional support from their health care provider as they cope with stressful social circumstances,” she said. “Despite the competing priorities, financial pressures, and other complexities health care organizations face with social health integration, they may be able to ease the burden for some patients through the power of caring conversations alone.”
Kaiser Permanente coauthors across the 4 papers are: Kathleen Barnes, Meagan Brown, Heidi Den Haan, John Ewing, Clarissa Hsu, Paula Lozano, Jess Mogk, Roy Pardee, Jessica Ridpath, Robert Wellman, and Emily Westbrook. Additional coauthors include former Kaiser Permanente researchers and staff: Katie Coleman, Cindee DeWitt, Amy Lee, Cara Lewis, Ammarah Mahmud, Sophia Mun, Consuelo Norris, Annie Piccorelli, and Callie Walsh-Bailey. External coauthors include India Ornelas, Michael Pullman, and Edwin Wong.
