Integrating social health into primary care is successful on a small scale, but what’s next? 

Sophia Mun and Ariel Singer share success stories from Community Resource Specialists pilot program 

May 26, 2023

Integrating social health into primary care is successful on a small scale, but what’s next?


Sophia Mun and Ariel Singer share success stories from Community Resource Specialists pilot program


Using patient-centered approaches, the Social Health Integration project partners with primary care delivery teams and patients to design and implement universal screening for social health. The project uses a universal screening approach at 2 Kaiser Permanente Washington primary care clinics to connect members who need assistance with social needs to the clinic’s Community Resource Specialists (CRSs). CRSs help members utilize community-based resources that meet their unique needs, such as housing, transportation, caregiving support, and healthy food access. 

SophiaMun_ArielSinger.pngThe CRSs and care delivery teams recently took part in interviews to share their insights about how the pilot in the 2 clinics is going. In this Q&A, research project manager Sophia Mun, MPH, who manages the project, and social health practice facilitator Ariel Singer, MPH, who facilitates between the project team and care delivery teams, share what the project has learned and explain what’s next. 

What has integrating CRSs brought to the pilot clinics? 

Sophia Mun (SM): CRSs specialize in helping members who are experiencing challenging life circumstances. They are extremely knowledgeable about local resources and do a lot of outreach and education around what resources are available in the community.  

Ariel Singer (AS): Primary care is notoriously fast paced, and the care delivery workforce already has so much to focus on. A dedicated CRS has time to stay with people as they navigate the sometimes complex and bureaucratic healthcare system and the expertise to explain the resources available. 

You recently interviewed the staff at the 2 pilot clinics. What are they saying about social health integration and the CRS role?  

AS: They’re glad that Kaiser Permanente Washington is asking members about social health because they recognize how critical social circumstances are for impacting people's health outcomes. The people I’ve talked to are grateful that there is a CRS on the team to link members to when issues arise.  

SM: Through the interviews, we’ve seen the impact the CRS work has had on members from the 2 social health integration pilot clinics. Raising awareness about what social needs are and how we are addressing them is important. The more we can communicate with providers and members about this work, the better. These stories help destigmatize the larger concept of social health and raise awareness about what the CRSs are capable of, and how they can assist patients with challenges outside of their physical health. 

Out of the success stories shared during these interviews, can you share one that stands out to you?

SM: One success story that stands out to me is about an older member with diabetes who had been losing weight but struggling to access healthy food. She didn’t know how to receive assistance and was hesitant to ask for help. Through the Social Health Questionnaire, she was connected to her clinic’s CRS, who helped her get access to state food benefits and to a farmers market program, and other incentives for healthy food purchases.  

This is just one story that exemplifies the great work that the CRSs do. Not only are they extremely knowledgeable about local and statewide benefits and resources, but they also provide kind, compassionate, and judgment-free care that makes members feel safe to share their concerns. 

AS: One story that stands out to me is about a member with breast cancer who wasn’t going to go to treatment because they didn’t have access to reliable transportation. The provider partnered with the clinic’s CRS, who ensured the member had the resources needed to accomplish their treatment and engage in the life-saving care required. 

These kinds of stories are important because they showcase how critical social circumstances are for impacting people's health outcomes.

Why is social health integration important to you?

AS: I regard social health as completely necessary but not yet sufficient in our country. The system is complex and fragmented, which leaves too many ways for people to get caught up or confused in it. These larger issues that cause people to have health-related social needs all stem from public policy. 

SM: I completely agree with Ariel. Social needs related to food or housing insecurity, or unreliable transportation exacerbate health disparities. If we can capture the data to show these needs are prevalent, then hopefully we can expand these efforts in other settings like urgent care or specialty clinics. The work starts here but there's a lot more to go. 

It sounds like you learned a lot from the workplace interviews. What’s next for social health integration?

SM: We need to communicate what social health is more effectively to members and care deliverers. We’ve talked about the avenues we can use to raise awareness of social health to members like explanations on tv screens in clinics and continued reinforcement about what integrating social health means. If members and care deliverers know about the amazing work CRSs do and the resources they provide and we have data to back that up, hopefully, we can get the resources we need from funders and leadership to continue moving forward. 

AS: I agree with Sophia that communication and education are our next steps. We need to communicate with the healthcare workforce so we can normalize social health integration. By providing more clarity on what social health is, workforce members will know what to expect when they refer somebody to a CRS. And we need to continue to educate members on what social health is to remove the stigmatization of asking for resources. Through the interviews I’ve conducted, it’s clear that the longer CRSs have been in the 2 pilot clinics, the more comfortable members are with answering questions about social needs in a healthcare setting. I’d like to see that positive trend keep going.