SONNET Project: Lewis

Project Summary

Through KP Washington's Learning Health System (LHS) Program, SONNET co-director Cara Lewis is partnering with delivery system leaders, care teams, and members to co-design an approach to conducting universal social health screening. The goal is to help KP Washington systematically identify social risk, provide resources to address unmet social needs, and deliver whole-person care to members. This project will leverage the Community Resource Specialist role in KP Washington, as well as KP National’s vision for a comprehensive social health practice across KP.

Our work in 2021 work will include:

• Identifying and engaging patient partners
   
• Working with clinics, care teams, and patient partners to develop workflows and patient care pathways and specify care team roles
   
• Developing process and outcome metrics
   
• Partnering with Care Delivery Technology Services to build technical tools to support the work
   
• Piloting implementation of integrated social health screening at two primary care clinics
   
• Developing provider and care team trainings on social risk-informed care and social needs-targeted care
   
• Preparing for scale and spread of integrated social health in 2022 and beyond  

This work will allow KP Washington to reliably, equitably, and routinely identify members with social needs and social risks—supporting personalized, individual care for better outcomes of our members. In addition, it will bolster population health management approaches that recognize social health factors in risk-stratification and facilitate outreach to those at risk for barriers to care. Finally, it will provide Insight into broader community needs and resources and inform how to make meaningful contributions to our community.

Contact SONNET

Email us at sonnet@kp.org to learn more about our work or request a consultation.