PHMI Social Health Framework and Approach

©️ 2024 Kaiser Foundation Health Plan, Inc.

This brief outlines the approach and underlying framework that the Practice Transformation Partners will use to incorporate social health work into the Population Health Management Initiative (PHMI). This approach will be adjusted and adapted to meet the needs of Community Health Centers (CHCs) as they are engaged in the work.

Defining Social Health

For the purposes of this work, we will use a social health lexicon defined by Alderwick and Gottlieb (2019) and adapted by Kaiser Permanente:^[1]

• Population health: The health outcomes of a group of individuals, including the distribution of such outcomes within the Social determinants are just one group of factors that shape population health, alongside healthcare, genetics, behaviors, commercial influences and others.
• Population health management (PHM): Population health management is a model of care that addresses individuals’ health needs at all points along the continuum of care, including in the community setting, through the participation and engagement of, as well as targeted interventions for, a defined population. The goal of population health management is to maintain and/or improve the physical and psychosocial well-being of individuals and to address health disparities through cost-effective and tailored health solutions.^[2]
• Structural determinants: The socioeconomic, political, cultural and institutional contexts and mechanisms that shape the social determinants of health.
• Social determinants of health (SDOH): Underlying communitywide social, economic and physical conditions in which people are born, grow, live, work and These determinants include income, education, employment, housing, neighborhood conditions, transportation systems, social connections and other social factors. These are also referred to as “social drivers of health.”
• Social risk factors: Specific adverse social conditions associated with poor health, like social isolation or housing instability.
• Social needs: Individual material resources and psychosocial circumstances required for long- term physical and mental health well-being, such as housing, food, water, clean air, sanitation and social Social needs are not necessarily synonymous with social risk factors – they also depend on people’s individual preferences and priorities.
• Social needs-informed care: Activities that involve modifications to traditional medical care to account for patients’ social circumstances – for example, providing transportation to hospital appointments or using data on patients’ access to food to inform decisions about medications.
• Social needs-targeted care: Activities in clinical settings that seek to address patients’ social needs directly – for example, helping patients access income assistance if they lack financial resources or linking patients with transportation, food or housing supports.

Framework Development

Our approach builds on a framework developed by Kaiser Permanente’s Social Health Design Team, which collected input from representatives who address social health within California’s CHCs to design their framework. It was tested through a plan-do-study-act (PDSA) process with select health centers, and the feedback was used to adjust the framework for the purposes of PHMI.

The PHMI Social Health Framework was also influenced by the National Academies of Sciences, Engineering, and Medicine’s “5 A’s” framework, as outlined in the following section.^[3]

PHMI Social Health Framework

The PHMI Social Health Framework, pictured below, incorporates individual-level and population-level approaches to improving social health.

The elements of the framework are outlined below.

• Assess and understand: Conduct an initial assessment of what information already exists about the community’s social health needs and the social health service system’s capacity and gaps. This should leverage existing data, including community health needs assessments that are conducted every three years to identify and measure community needs and assets. This data may be used to establish or adjust patient screening practices (who and what to screen for based on population needs and assets), to understand community assets and population-level needs, to inform equity interventions, and to establish where and how to connect patients with social needs.

Over time, this step also will include an assessment of individual-level data that comes out of each step of the framework to determine whether identified needs are being addressed, to identify inequities in access, and to ensure the quality of services or outcomes among subpopulations.

The PHMI Equity Framework and Approach also can inform this part of the process: It can ensure that all equity-related data that is collected through PHMI is used to enhance CHCs’ understanding of their patient populations and their social health needs.

Additionally, this step should include reflections on and adaptations to the approach that allow for adjustments to screenings over time, reprioritization as needs and assets change, and identification of data-sharing opportunities across organizations.

Screen patients: Based on an initial assessment of community social health needs and assets, screen patients from the population(s) of focus for priority social health needs during clinical visits. This screening process will be informed by the PHMI Equity Framework and Approach, which will guide CHCs in considering equity when making decisions about prioritization. It is important to note that, in some cases, this screening may be done by community-based organization (CBO) partners, who will then refer patients to CHCs.

Individual level

• Assess and adjust care plan: Care team members further assess patient needs, and clinicians and patients use the social needs information to co-design a care plan and approach to care. This process will be repeated at regular intervals to ensure care continues to meet patients’ evolving needs.
• Connect to resources: CHC patients are connected to social health resources and interventions within and external to the CHC. In some cases, a single social health need may need to be addressed with multiple resources or interventions.
• Follow up: Social health referrals are tracked and monitored to confirm that services are received and needs are addressed. Additionally, member experience is assessed.

Population level

• Identify needs and resources: Population-level social health needs are identified using patient screening data, care team assessments and other data. Existing social health resources are identified to meet these needs; this information will guide efforts to develop or enhance CBO partnerships.
• Partner with CBOs: Establish partnerships in the community to address the most pressing social needs and leverage essential resources that support or assist CHC patients. The PHMI Equity Framework and Approach will inform partnership development to ensure the work of partnership building prioritizes community groups that experience injustice and structural violence. This should include efforts to understand where CHC patients and families feel supported, which organizations or groups they rely on in the community, and how patients and families support each other’s well-being. Partnership-building efforts should be based on the gathered information. This work will require significant internal CHC resources and a new approach to deeply engage community partners and shared stakeholders.
  • Optimize community resources and infrastructure: Build community collaborations that facilitate access and enhance social health service alignment to address the social needs of CHC patients, including Community Supports, Enhanced Care Management, CalFresh, and other local efforts and government resources.

Though the framework outlines a series of activities, it should be applied flexibly to align with a CHC’s needs and capacities. Health centers may start at different points in the framework and may conduct activities concurrently or in a different order. Importantly, the activities in the framework should inform each other and should guide health centers through iteration and improvement of their social health work over time. For example, as population-level social health needs are better understood through individual screening, health centers may pursue and strengthen new community partnerships to better meet the needs and build on the existing assets of their population.

The application of this framework also will be informed by and integrated with the PHMI Equity Framework and Approach. The integration of these two frameworks is essential because of the inextricable links between social risk factors, health-related social needs, social drivers of health, structural determinants and equity.

Leveraging California Advancing and Innovating Medi-Cal (CalAIM) Resources

Through California Advancing and Innovating Medi-Cal (CalAIM), the California Department of Health Care Services (DHCS) is investing billions of dollars into the health of Medi-Cal enrollees with complex health needs and unmet social needs. One of the primary ways CalAIM is addressing social needs is through Community Supports, which is a set of 14 services optionally provided by Medi-Cal managed care plans in lieu of traditional medical services. Through Community Supports, Medi-Cal dollars are being leveraged to build community-based resources and networks of organizations that provide services to meet social health needs. Initially, PHMI support for screening, linkage and partnership efforts for social needs will focus on the 14 Community Supports covered through CalAIM:

• Housing transition navigation services.
• Housing deposits.
• Housing tenancy and sustaining services.
• Short-term posthospitalization housing.
• Recuperative care (medical respite).
• Day habilitation programs.
• Caregiver respite services.
• Nursing facility transition/diversion to assisted living facilities.
• Community transition services/nursing facility transition to a home.
• Personal care and homemaker services.
• Environmental accessibility adaptations (home modifications).
• Medically supportive food/meals/medically tailored meals.
• Sobering centers.
• Asthma remediation.

Over time, other areas of need and opportunity may be identified.

In this context, PHMI support to CHCs through the Social Health Framework and Approach will include guidance on the following: how to identify the Community Supports being provided by managed care plans in their county, how to screen patients for Community Supports eligibility, and how to identify and build relationships with contracted Community Supports providers and managed care plans in their communities. This ensures that CHCs are accessing and leveraging the influx of state resources aimed at meeting social health needs. Ultimately, improved partnerships with CBOs and managed care plans will strengthen the referral systems in the community.

Integration Into Training and Technical Assistance

This framework will guide social health-related work across the PHMI. It will be integrated into all training and technical assistance efforts as appropriate. This includes the following.

• Implementation guides: The PHMI Social Health Framework and Approach will be integrated into the PHMI Population of Focus (PoF) implementation guides, where it will be tailored to apply specifically to each This will include:
  • Information on specific social health needs that may be most prevalent among or relevant to the PoF.
  • Guidance on screening and connecting to community resources for the PoF’s high-priority needs.
  • A section on Community Supports opportunities relevant to the PoF.
  • “Minimum standards” for the degree of implementation of the Social Health Framework and Approach for each
• Coaching: Coaches will work with health centers to adjust and implement the framework based on what they are already doing, what they already know about the communities they serve and available community resources, and where they need This support could include adapting screening tools appropriate for the PoF; assessing existing and possible partnerships with CBOs (with an initial emphasis on CBOs and networks contracted to provide Community Supports); identifying best practices for care plan adjustments; adjusting workflows to accommodate screenings and referrals; establishing data-sharing arrangements with referral partners; and identifying and addressing staffing, workforce and training needs, including the role of community health workers and Promotores in screening and linkages. Coaches may also help health centers identify and assess their foundational capacities that need to be strengthened to support social health (and other population health management) work, using the Levels of HRSN [health-related social needs] & SDH [social determinants of health] Integration Framework or a similar tool as guidance.^[4] This could include assessing necessary data system modifications, identifying core teams to manage the work, creating accountability and leveraging leadership buy-in to facilitate change.
• Learning events: Social health work also may be advanced through learning events, which will focus in part on areas of shared challenge that are elevated by coaches.
• Data and technology: Practice Transformation Partners will work with CHCs to build relationships and collaborate with other stakeholders who collect and use social health-related data to support bidirectional sharing of relevant data in usable formats. This support may include guidance on scope and processes for data sharing, implementation of data standards to support data exchange, development and implementation of staff training and protocols to support standardized data collection for social health and equity-related data, use of new or expanded technologies and platforms that provide linkages to existing databases, and appropriate use of patient-facing technologies to support assessment and care.