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Volume 4, Issue 1
Why Look at Social Needs?

What's going on?

Increasingly, Kaiser Permanente (KP) members are being screened for social needs in the care delivery setting. We are leading the way in addressing social needs in collaboration with community organizations. In growing recognition of the importance of assessing social needs, KP’s Care Management Institute (CMI) developed a Social Needs Assessment (SNA) Measurement report. The overarching goal of this work is to align interregional social needs assessment measures to drive improvement across regional efforts.

In this report...

This report includes the first cross-regional measurement of responses to the Your Current Life Situation Survey (YCLS) questions. Across KP, regions have been using the YCLS questions and other social needs assessments to evaluate and understand social needs of KP members. This report provides early insight into the current level of social needs across KP.

The YCLS has primarily been administered to KP members at high risk for social needs, rather than to a cross-section of all KP members. The focus of this report is KP members who have the highest social needs as reported from the third quarter of 2017 through the second quarter of 2019. Social needs were measured in clinical programs in four regions (Northern California, Colorado, Georgia, and Northwest).

28% of members assessed in programs for high risk members reported at least one social need. The most common need was financial strain (17%) and then food insecurity (12%).

Figure 1: Percent of All Members Reporting Social Needs Category (Q2 2019)

Percent of All Members Reporting Social Needs Category (Q2 2019)



Members with greater numbers of unmet social needs were also more likely to report “difficulties piling up so high you could not overcome them,” responses: “sometimes,” “fairly often,” or “very often.” This single question thus summarizes the impact of these multiple needs.

Figure 2: Percent of Members with Difficulties Piling Up by Count of Social Need (2019)

Percent of Members with Difficulties Piling Up by Count of Social Need (2019)


Many members who report needs do not say they want KP to help resolve these needs. Data are more discordant for individual needs such as food or housing, and least discordant for financial strain.

A better understanding of the reasons for this discordance can help KP clinicians and staff provide help to those who desire it while honoring the autonomy of those who do not currently desire KP assistance. This issue was also explored in a November 2019 Issue Brief.

Figure 3: Percent of Members Wanting Help as Subset of Members who Reported Need (Q1-Q2 2019)

Percent of Members Wanting Help as Subset of Members who Reported Need (Q1-Q2 2019)

The findings...

These findings raise important implications for KP. Such data can be used in many ways, from developing individual care plans to identifying vulnerable member segments and communities at risk. To date, social needs data have not been collected systematically. As a result, it has been difficult to assess general trends in social needs over time from care delivery data. As KP regions switch to the Epic social needs module, these questions will need to be addressed in order to accurately compare trends over time.

These findings also suggest that there are opportunities for research to better understand the gaps between members reporting needs and wanting help with their needs or members reporting wanting help but not reporting a need. In addition, as KP builds out Thrive Local*, there will be questions around referrals and how frequently follow-up is done.


* Thrive Local, an inter-regional network developed in partnership with Unite Us, that will connect KP members who have pressing social needs such as housing, food, safety and utilities with community resources that can address those needs.

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