SONNET Project: Clennin

SONNET is a national network of applied researchers who help design, evaluate, and implement effective social health interventions to improve member health across Kaiser Permanente. SONNET's work is made possible with funding from KP's National Community Health Program.

Social Needs, Essential Resources, and Health: Evaluating the association between social needs, health care utilization, chronic disease indicators, and neighborhood resources

Project Team 

  • Morgan Clennin, PhD, Principal Investigator, KP Colorado Institute for Health Research (IHR) 
  • Cheryl Kelly, Co-Investigator, KPCO IHR 
  • Heather Spencer Feigelson, Co-Investigator, KPCO, IHR 
  • Mario Schootman, Consultant, Director of the Department of Clinical Analytics at the Center for Clinical Excellence at SSM Health

Project Summary  

Our neighborhood, or where we live, can have a major impact on our health. 

Studies have shown that health is affected by the resources in our neighborhood. This includes housing and access to health care, schools, and jobs. These social determinants of health (SDoH) significantly contribute to health disparities, preventable use of healthcare services, and increased health care costs. Growing disparities in health have elevated the need to address social health and highlighted the importance of a comprehensive strategy that includes both targeted individual-level interventions and broader community-level policy and practice changes. 

Kaiser Permanente (KP) has committed to addressing members’ social needs. To build upon KP’s initial report describing the prevalence of social needs among our members, our 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. We propose two specific aims: (1) To examine the relationships between social needs, health care utilization, and indicators of chronic disease; and (2) To assess how the availability of resources within members’ neighborhood environment are related to members’ social need(s).  

The overall goal of our project is to inform clinic-based approaches to improve member outcomes (e.g., screening and referral workflows); and identify leverage points for community-based interventions to ensure access to essential resources to address members’ social needs


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