Social Determinants of Health
Addressing the social determinants of health in its members and their communities is an organizational priority for Kaiser Permanente. Social determinants of health are the conditions in which people are born, grow, work, live and age, and the wider set of forces shaping the conditions of daily life. IHR researchers have focused attention on health care system interventions to identify and ease basic resource needs (food insecurity, housing instability, and inability to pay for transportation, energy/utilities, and medical costs). We collaborate with organizational leaders at Kaiser Permanente Colorado, other KP regions, and KP Program Office to conduct evaluations and research on the effectiveness of these interventions in improving a wide array of health outcomes.
Social Determinants of Health Researchers
Featured Projects
Investigators: Morgan Clennin, PhD, MPH and Sheridan Green, PhD, MS
Funder: Colorado Department of Public Health & Environment, Office of Health Equity
Study End Date: 06/30/2025
- The CDPHE Office of Health Equity funds two separate grant programs under the Health Disparity and Community Grant Program (HDCGP, two programs under a single contract)
- The first grant program funded 14 lead agencies with multi-sector partnerships to implement evidence-based strategies to overcome health disparities in the prevention, early detection, and treatment of cancer, cardiovascular and pulmonary diseases in underrepresented populations by working on systems and policy changes that are community led. Community organizations were funded by the Health Disparities and Community Grant Program (Amendment 35). The goal of this evaluation was to conduct a comprehensive evaluation to assess 1) how the grant program built community power through authentic community engagement, capacity building, and establishing strategic and diverse partnerships; 2) the extent to which improved community power advanced progress towards policy, system, and environmental (PSE) changes to improve social infrastructure (e.g., housing insecurity, food insecurity, unemployment); and 3) the impact of achieved PSE changes on access to upstream social and economic resources (that will eventually lead to improved health outcomes and reduced health inequities and disparities).
- The second grant program provided funding to 30 community and grassroots organizations to develop local plans and capacity toward achieving health equity. Goal is to create a foundation to improve social infrastructure and health outcomes that eventually lead to the reduction of health inequities and disparities. Funds are explicitly intended for projects that create and/or launch a foundation for making changes to public, systems-level, and/or organizational practices, rules, laws, and regulations that influence the health of underrepresented communities. Using the power ecosystem framework, the goal of this project is to conduct a comprehensive evaluation to document how grantees’ build community power and resilience; develop community-led, collaborative solutions that contribute to systemic change; and shift power in communities.
Funder: Colorado Department of Public Health & Environment, Office of Health Equity
Study End Date: 06/30/2025
Investigator: Sheridan Green, PhD, MS
Project HOME is an initiative out of Kaiser Permanente National Community Health. The goal is to rapidly house a targeted segment of Kaiser Permanente’s unhoused member population through an innovative housing model. HOME will be implemented in northern and southern California and the Portland, Oregon area. Dr. Green and team are leading the evaluation of the initiative. The aims of this project include a process evaluation to understand the operational viability of the Project HOME initiative (e.g., appropriate and effective workflows established in each region) as well as an outcome (e.g., members housed, members satisfied, appropriate utilization of health system) and impact evaluation (e.g., members improve social, mental, physical health and improvements in cost outcomes).
Funder: Kaiser Permanente National Community Health
Study End Date: 12/31/2024
Project HOME is an initiative out of Kaiser Permanente National Community Health. The goal is to rapidly house a targeted segment of Kaiser Permanente’s unhoused member population through an innovative housing model. HOME will be implemented in northern and southern California and the Portland, Oregon area. Dr. Green and team are leading the evaluation of the initiative. The aims of this project include a process evaluation to understand the operational viability of the Project HOME initiative (e.g., appropriate and effective workflows established in each region) as well as an outcome (e.g., members housed, members satisfied, appropriate utilization of health system) and impact evaluation (e.g., members improve social, mental, physical health and improvements in cost outcomes).
Funder: Kaiser Permanente National Community Health
Study End Date: 12/31/2024
Investigator: Sheridan Green, PhD, MS
The MLP Evaluation is a cross-site evaluation intended to test a model within Kaiser Permanente’s clinical care and health plan to understand the initiative’s operational viability, shared value, and health care utilization outcomes. The study examines the reach of the MLP initiative in terms of the characteristics of those receiving legal services and resolution of needs, and the impact on those specifically receiving legal services related to housing in terms of their health, social needs, and use of healthcare services.
Funder: Kaiser Permanente National Community Health
Study End Date: 12/31/2024
The MLP Evaluation is a cross-site evaluation intended to test a model within Kaiser Permanente’s clinical care and health plan to understand the initiative’s operational viability, shared value, and health care utilization outcomes. The study examines the reach of the MLP initiative in terms of the characteristics of those receiving legal services and resolution of needs, and the impact on those specifically receiving legal services related to housing in terms of their health, social needs, and use of healthcare services.
Funder: Kaiser Permanente National Community Health
Study End Date: 12/31/2024
Investigator: Morgan Clennin, PhD, MPH
Our primary goal is to identify social risk(s) that are most associated with member retention and healthcare utilization. This project will expand upon our prior cross-sectional work and also incorporate 2022 National SHS survey data and prospective EHR data to examine the longitudinal relationship between social risk and utilization outcomes. Guided by Andersen’s Behavioral Model for Health Services Use, our project aims to: 1) describe longitudinal changes in member-reported social risks and social needs as assessed via the 2020 and 2022 National SHS surveys and EHR social risk screening data (e.g., EPIC SDoH Wheel); 2) explore the extent to which cumulative social risk exposures are associated with member retention; and 3) examine the longitudinal association between member-reported social risks, social needs, and health care utilization (i.e., ED and hospitalization encounters).
Funder: Kaiser Permanente Social Needs Network for Evaluation and Translation (SONNET)
Study End Date: 12/2023
Our primary goal is to identify social risk(s) that are most associated with member retention and healthcare utilization. This project will expand upon our prior cross-sectional work and also incorporate 2022 National SHS survey data and prospective EHR data to examine the longitudinal relationship between social risk and utilization outcomes. Guided by Andersen’s Behavioral Model for Health Services Use, our project aims to: 1) describe longitudinal changes in member-reported social risks and social needs as assessed via the 2020 and 2022 National SHS surveys and EHR social risk screening data (e.g., EPIC SDoH Wheel); 2) explore the extent to which cumulative social risk exposures are associated with member retention; and 3) examine the longitudinal association between member-reported social risks, social needs, and health care utilization (i.e., ED and hospitalization encounters).
Funder: Kaiser Permanente Social Needs Network for Evaluation and Translation (SONNET)
Study End Date: 12/2023
Investigator: Morgan Clennin, PhD, MPH
The Colorado Women, Infants, and Children (WIC) Produce Box program aims to reduce food insecurity and increase access to healthy and nutritious foods. This program is a local initiative to provide fresh, high-quality produce directly from local growers to participating WIC households. While the program demonstrated success, little is known about how to effectively scale up the program and how program expansion might impact the distribution of locally sourced healthy produce. To address this gap, Nourish Colorado and Kaiser Permanente Institute for Health Research are employing a mixed methods evaluation approach to identify: 1) how participation in this program impacts suppliers; 2) strategies for scaling the delivery of the program; and 3) potential leverage points for policy interventions to support suppliers continued commitment to support such of programs. Local growers will be actively engaged in the evaluation and help identify viable strategies to scale up the program. Our findings will generate actionable evidence to guide the transformation of local food systems and identifying sustainable pathways to translate an evidence-based healthy food incentives program into practice.
Funder: NIH/NCATS Colorado CTSA
Study End Date: 04/2023
The Colorado Women, Infants, and Children (WIC) Produce Box program aims to reduce food insecurity and increase access to healthy and nutritious foods. This program is a local initiative to provide fresh, high-quality produce directly from local growers to participating WIC households. While the program demonstrated success, little is known about how to effectively scale up the program and how program expansion might impact the distribution of locally sourced healthy produce. To address this gap, Nourish Colorado and Kaiser Permanente Institute for Health Research are employing a mixed methods evaluation approach to identify: 1) how participation in this program impacts suppliers; 2) strategies for scaling the delivery of the program; and 3) potential leverage points for policy interventions to support suppliers continued commitment to support such of programs. Local growers will be actively engaged in the evaluation and help identify viable strategies to scale up the program. Our findings will generate actionable evidence to guide the transformation of local food systems and identifying sustainable pathways to translate an evidence-based healthy food incentives program into practice.
Funder: NIH/NCATS Colorado CTSA
Study End Date: 04/2023
Investigator: Morgan Clennin, PhD, MPH
Newly enacted Colorado HB1309, 1196, and 1201 require the Colorado Division of Housing to institute new regulations for manufactured housing parks and grants cities the authority to enact ordinances that support the safe and equitable operation of these communities. This study will evaluate the implementation process and impact of these policies in 3 different Colorado communities. The first aim is to use a case study approach and conduct a policy implementation evaluation of all 3 policies to determine how implementation varied across three diverse Colorado communities. The second aim is to use a cross-sectional pre-post design to assess the impact of all 3 policies on housing security, safety, and affordability in all 3 communities. This study will fill a gap in the literature by assessing how these statewide policies are implemented in three different small to moderate-sized communities and the impact of the policy on the housing security of the residents who live there.
Funder: Robert Wood Johnson Foundation
Study End Date: 01/31/2023
Newly enacted Colorado HB1309, 1196, and 1201 require the Colorado Division of Housing to institute new regulations for manufactured housing parks and grants cities the authority to enact ordinances that support the safe and equitable operation of these communities. This study will evaluate the implementation process and impact of these policies in 3 different Colorado communities. The first aim is to use a case study approach and conduct a policy implementation evaluation of all 3 policies to determine how implementation varied across three diverse Colorado communities. The second aim is to use a cross-sectional pre-post design to assess the impact of all 3 policies on housing security, safety, and affordability in all 3 communities. This study will fill a gap in the literature by assessing how these statewide policies are implemented in three different small to moderate-sized communities and the impact of the policy on the housing security of the residents who live there.
Funder: Robert Wood Johnson Foundation
Study End Date: 01/31/2023
Investigator: Sheridan Green, PhD, MS
This national project is assessing the implementation and effectiveness of the Thrive Local initiative (across 8 Kaiser Permanente regions). Thrive Local consists of three key functions: a resource directory that provides up-to-date and searchable information on community resources; geographically based networks of social service organizations; and a technology platform that engages clinicians and staff, members, and employees of community organizations to make rapid, secure referrals between health care providers and social care providers and track the outcomes of those referrals. The evaluation is using a mixed methods approach, combining qualitative data on implementation and user experience with quantitative data on reach of the initiative and individual patient outcomes. The implementation evaluation is assessing the extent to which the social needs system elements are in place and functioning. The outcome evaluation is assessing the overall reach of the Thrive Local, including the characteristics of patients who consent to participate and receive services from CBOs and the overall effectiveness of Thrive Local on reducing patients’ social need burden over time and improved health outcomes.
Funder: Kaiser Permanente National Community Health
Study End Date: 12/31/2022
This national project is assessing the implementation and effectiveness of the Thrive Local initiative (across 8 Kaiser Permanente regions). Thrive Local consists of three key functions: a resource directory that provides up-to-date and searchable information on community resources; geographically based networks of social service organizations; and a technology platform that engages clinicians and staff, members, and employees of community organizations to make rapid, secure referrals between health care providers and social care providers and track the outcomes of those referrals. The evaluation is using a mixed methods approach, combining qualitative data on implementation and user experience with quantitative data on reach of the initiative and individual patient outcomes. The implementation evaluation is assessing the extent to which the social needs system elements are in place and functioning. The outcome evaluation is assessing the overall reach of the Thrive Local, including the characteristics of patients who consent to participate and receive services from CBOs and the overall effectiveness of Thrive Local on reducing patients’ social need burden over time and improved health outcomes.
Funder: Kaiser Permanente National Community Health
Study End Date: 12/31/2022
Investigator: Morgan Clennin, PhD, MPH
Evidence confirms social determinants of health (SDoH) significantly contribute to health disparities, preventable use of healthcare services, and increased health care costs. This study proposes to link KP National Social Needs survey data with clinical outcomes and neighborhood data to identify promising leverage points to inform social health policy and practice. The goal of this project is two-fold: 1) inform clinic-based interventions to improve member outcomes (e.g., screening and referral workflows); and 2) identify key leverage points for community-based interventions to ensure availability and accessibility of social needs resources.
Funder: Kaiser Permanente Social Needs Network for Evaluation and Translation (SONNET)
Study End Date: 12/2022
Evidence confirms social determinants of health (SDoH) significantly contribute to health disparities, preventable use of healthcare services, and increased health care costs. This study proposes to link KP National Social Needs survey data with clinical outcomes and neighborhood data to identify promising leverage points to inform social health policy and practice. The goal of this project is two-fold: 1) inform clinic-based interventions to improve member outcomes (e.g., screening and referral workflows); and 2) identify key leverage points for community-based interventions to ensure availability and accessibility of social needs resources.
Funder: Kaiser Permanente Social Needs Network for Evaluation and Translation (SONNET)
Study End Date: 12/2022
Investigator: John F. Steiner, MD, MPH
The goal of this project is to establish a learning network, the Social Needs Network for Evaluation and Translation (SONNET), to promote rigorous evaluation of Kaiser Permanente programs that address social, economic and behavioral needs (SEBN) among Kaiser members.
Funder: Kaiser Permanente Community Health
Study End Date: 12/31/2020
The goal of this project is to establish a learning network, the Social Needs Network for Evaluation and Translation (SONNET), to promote rigorous evaluation of Kaiser Permanente programs that address social, economic and behavioral needs (SEBN) among Kaiser members.
Funder: Kaiser Permanente Community Health
Study End Date: 12/31/2020
Investigators: Anh Nguyen, PhD , Ingrid A. Binswanger, MD, MPH, MS and Jason M. Glanz, PhD
This study examines factors associated with insurance instability and assesses the association of insurance coverage gaps and mortality in patients receiving treatment for opioid use disorder.
Funder: National Institute on Drug Abuse’s Clinical Trials Network
Study End Date: 09/30/2024
This study examines factors associated with insurance instability and assesses the association of insurance coverage gaps and mortality in patients receiving treatment for opioid use disorder.
Funder: National Institute on Drug Abuse’s Clinical Trials Network
Study End Date: 09/30/2024