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

Investigator: Cheryl Kelly, PhD, MPH, MA
This national project is assessing the implementation and effectiveness of the Thrive Local initiative (across 8 Kaiser Permanente regions). Thrive Local links clinical care to social care through data integration with community-based partner organizations. 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
Investigators: Cheryl Kelly, PhD, MPH, MA and 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: 11/30/2022
Investigators: Cheryl Kelly, PhD, MPH, MA and Morgan Clennin, PhD, MPH
The goal of this project is to conduct a comprehensive cross-site evaluation of 22 organizations or sites implementing strategies ranging from healthy eating and active living policies to clinical system improvements to health behavior improvement programs (e.g., Diabetes Prevention Program). The purpose of the cross-site evaluation is to document and assess changes in healthy behaviors (e.g., physical activity, healthy eating, HPV vaccination, self-measured blood pressure) and health outcomes (e.g., diabetes, cardiovascular disease, hypertension) over a three-year period. Two in-depth evaluations are also being implemented. First, an in-depth policy impact assessment is being implemented to provide estimates of the impact of policy changes on health behaviors and health outcomes and assess the quality of the policy and the intended and unintended consequences of the change. Results will inform and improve policy development, adoption, implementation, and effectiveness and build the evidence base for policy interventions. Second, behavior change programs are incorporating screening and referring for food insecurity and housing insecurity. An in-depth evaluation is being conducted to understand the barriers and facilitators to incorporating this process into their program workflows and to assess who is screened and screens positive for a need and the characteristics of individuals who accept assistance and ultimately receive assistance.
Funder: Colorado Department of Public Health & Environment
Study End Date: 12/31/2021
Investigators: Cheryl Kelly, PhD, MPH, MA and Morgan Clennin, PhD, MPH
The Office of Health Equity’s (OHE) Health Disparities Grant Program (HDGP) is providing support to agencies across Colorado to address upstream determinants of health (e.g., housing, education) with the goal of improving downstream health outcomes (e.g., access to care, decreased chronic disease rates). The goal of this project is to conduct a comprehensive cross-site evaluation of these funded agencies implementing system or policy changes that reduce health disparities (e.g., housing insecurity, food insecurity, unemployment). The evaluation is assessing the role of community engagement, community capacity building, and multisectoral partnerships in advancing the community’s collective action to solve problems and how that informed policy, environmental, and system changes designed to improve access to social and economic resources. Innovative methods have been developed to measure authentic community engagement and the role of partners and community members in making decisions. Additionally, an in-depth evaluation is being conducted to assess how the partnership network and community engagement helped drive the prioritization and adoption of PSE changes.
Funder: Colorado Department of Public Health & Environment, Office of Health Equity
Study End Date: 06/30/2021
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
Investigator: Anh Nguyen, 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:  STAR
Study End Date: 12/31/2020