Leveraging research capabilities to advance social health
Meagan Brown presents on Kaiser Permanente’s social health research agenda at the 2025 Social Interventions Research & Evaluation Network (SIREN) research meeting
How Kaiser Permanente works with SONNET and ACT Center to address members’ social needs in Washington and beyond
By Meagan Brown, PhD, MPH, an assistant investigator with the Center for Accelerating Care Transformation (ACT Center) at Kaiser Permanente Washington Health Research Institute (KPWHRI) and director of Kaiser Permanente’s Social Needs Network for Evaluation and Translation (SONNET)
Over the last several years, improving patients’ social health has increasingly become a priority for health care organizations nationwide. Social health (sometimes called social determinants of health or health-related social needs) refers to the conditions in which people live their daily lives — such as having secure housing, enough healthy food to eat, and reliable transportation.
With a growing body of evidence showing that social needs play a larger role in overall population health than clinical care, assessing patients’ social needs has been incorporated into health care quality assessments and reimbursement incentives across organizations such as the National Committee for Quality Assurance (NCQA), the Joint Commission, and the Centers for Medicare and Medicaid Services. In 2023, NCQA rolled out a new HEDIS quality measure specific to social need screening and interventions. By then, Kaiser Permanente had long been leveraging its scientific capabilities to inform regional and systemwide efforts to implement social needs screening and to design and test interventions to help members who would like assistance with social needs.
For the past several years, I’ve had the pleasure of leading exciting work in social needs research and evaluation through 2 Kaiser Permanente collaborations:
- The Social Needs Network for Evaluation and Translation (SONNET), which brings together researchers and operational leaders from Kaiser Permanente National and the organization’s 8 regional markets via a coordinating center housed at Kaiser Permanente Washington Health Research Institute (KPWHRI). SONNET’s goal is to address our members’ social needs by designing, evaluating, and implementing screening methods that identify social needs, as well as interventions that help resolve them.
- The Center for Accelerating Care Transformation (ACT Center) at KPWHRI, which leads Kaiser Permanente Washington’s Learning Health System (LHS) Program — including several projects focused on integrating social needs screening into primary care. Through the LHS Program, the ACT Center brings together researchers and health care leaders in timely consultations and evaluations that help Kaiser Permanente Washington improve care and member health in ways that are practical, patient-centered, and evidence-based.
How SONNET helps Kaiser Permanente achieve large-scale improvements in members’ social health
SONNET was established in 2017 and is funded by the Kaiser Permanente Office of Community Health and Social Health to inform and advance Kaiser Permanente’s Social Health Practice (SHP) objectives by tapping into the organization’s enterprise-wide research capabilities. I’ve had the pleasure of being part of SONNET since KPWHRI became the network’s coordinating center in 2021 and currently serve as its director.
Much of SONNET’s early work was focused on identifying operational leaders’ top priorities for learning and action and helping SHP leaders understand the prevalence and types of social needs among Kaiser Permanente members nationwide. Among my first SONNET projects were Kaiser Permanente’s National Social Health Survey in 2020 and 2022, which assessed the social needs of thousands of adult members in all 8 Kaiser Permanente markets. Both surveys indicated a high prevalence of social needs among members nationwide — with 2022 results showing that:
- More than 2 in 3 members (68%) have at least 1 social need, and 90% of members with Medicaid plans have at least 1 social need.
- Members with any social need are 6 times more likely to report fair or poor mental/emotional health and 3 times more likely to report fair or poor physical health.
- 61% of members with social needs are interested in receiving assistance from Kaiser Permanente.
In intersectional analyses of the 2020 survey results, we also examined how the overlapping social identities of age, income, gender, and race and ethnicity are associated with social need — finding that needs are higher among specific intersectional groups, especially lower-income, older-age adults who are Black, Pacific Islander, or multi-racial. This points to the importance of investing not just in social needs screening but also in upstream changes to improve the social safety net and advance policies to reduce racial and economic inequities.
Creating this vast, representative data resource has also allowed SONNET to examine links between social needs and important outcomes, such as member health and health care costs and utilization. Our most recent findings showed that people who report social needs are 21% more likely to visit the emergency department. In another recent analysis, we found that people who experience severe housing instability are nearly twice as likely to have severe obesity — independent of age, sex, race and ethnicity, socioeconomic factors, and health status.
With a better understanding of members’ social needs nationwide, SONNET pivoted in 2025 to focus our scientific capabilities on rapid-cycle evaluations to inform Kaiser Permanente’s efforts to improve services offered in its Community Support Hub — a resource available to all members. The hub provides a call center and online directory to help members find community-based programs and services in their region and offers community resource hub specialists to help members connect to those resources.
Our early findings are pointing to areas where we are doing well at reaching members — and to other areas where we have opportunities to boost outreach and engagement in the hub and to improve data collection to better understand what happens when members seek out resources in their communities.
How the ACT Center partners with Kaiser Permanente Washington to integrate social health into primary care
KPWHRI has been a pioneer in research to support the integration of social health into primary care for more than a decade. After a 2012 study funded by the Patient-Centered Outcomes Research Institute showed that having community resource specialists (CRSs) work with members to address social needs benefited members and care teams alike, Kaiser Permanente Washington implemented the CRS role in primary care teams systemwide.
Through the LHS Program, the ACT Center then led a project to optimize CRS implementation — creating a CRS Integration Playbook that’s publicly available in the center’s resource library. As a next step, the ACT Center partnered with Kaiser Permanente Washington leaders and care teams on the Social Health Integration (SHI) pilot, which focused on finding the best ways to boost social needs screening rates and to connect members with helpful resources.
Now, I’m excited to be able to leverage what we learned through the CRS and SHI projects to inform Kaiser Permanente Washington’s next effort to address members social needs: creating evidence-based social health screening pathways to help ensure members are getting screened for social needs and connected to helpful services and resources. Our initial focus is to understand the different ways that social needs screening is being conducted in daily practice and to find practical, patient-centered ways to improve the process for members and care teams alike.
I look forward to continuing to partner with health care leaders at Kaiser Permanente Washington to spread and sustain efforts to help members address their social needs and to support them in improving their social health alongside their physical and mental health.
