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Social Determinants of Health: working with social workers and social work managers to build capacity to screen and refer in the medical setting

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Social Determinants of Health: working with social workers and social work managers to build capacity to screen and refer in the medical setting

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Content SOCIAL DETERMINANTS OF HEALTH: WORKING WITH SOCIAL WORKERS
AND SOCIAL WORK MANAGERS TO BUILD CAPACITY TO SCREEN AND REFER
IN THE MEDICAL SETTING
GRAND CHALLENGES: CLOSING THE HEALTH GAP and ACHIEVE EQUAL
OPPORTUNITY AND JUSTICE
by
Ruth A. Vosmek, LCSW
A Capstone Project Presented to the
FACULTY OF THE USC SUZANNE DWORAK-PECK SCHOOL OF SOCIAL WORK
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
Doctor of Social Work
August 2024

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TABLE OF CONTENTS
Page Number
I. Abstract 3
II. Acknowledgements 4
III. Positionality Statement 5
IV. Problem of Practice and Literature Review 7
V. Conceptual/Theoretical Framework 9
VI. Methodology 13
VII. Project Description 15
VIII. Implementation Plan 22
IX. Evaluation Plan 23
X. Challenges/Limitations 27
XI. Conclusions and Implications 29
XII. References 31
XIII. Appendices
Appendix A: Marketing Tools and Speaker Bio 36
Appendix B: Design Brief 39
Appendix C: Design Criteria 41
Appendix D: Logic Model 42
Appendix E: Budget (Implementation and First Year) 44
Appendix F: User Journey Map 46
Appendix G: Timeline 47
Appendix H: Sample Social Work Survey 48
Appendix I: Implementation Manual (Capstone High Fidelity Model) 51

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Closing the Health Gap Through SDOH Screening in Large Medical System
Abstract
According to the Joint Commission (TJC), The Social Determinants of Health (SDOH)
account for 80-90% of modifiable contributors to health outcomes. Because of this, TJC along
with Centers for Medicare and Medi-Cal services (CMS) are mandating that accredited hospitals
and health systems identify and address SDOH. Despite the mandate, there are barriers to
assessing for and addressing SDOH. Kaiser Permanente Northern California (KP NCAL) is
designing new systems for identification of SDOH. This capstone helped to hone the tools
developed in EPIC (Electronic Health Record platform). Using human centered design, this
capstone project involved over 35 Kaiser Permanente training presentations enabling the
identification of barriers to full implementation of the mandate, including screening and
utilization of tools and resources to help patients (micro level). Findings and strategies for
addressing obstacles were then incorporated into an Implementation Manual for Social Work
Managers. Specific challenges to screening including areas of resistance, barriers, and challenges
to the goals associated with the SDOH project are discussed using Kotter’s organizational
change and Satir’s individual change models, along with recommendations for overcoming these
challenges with the goal of increasing Kaiser’s ability to get accurate data and meet the SDOH
needs of patients more efficiently and effectively. Data collection activities and
Bronfenbrenner’s ecological framework of associated organizational Mezzo- and Macro- level
goals are also discussed. This SDOH helps to create equity and close the health gap, one of the
Grand Challenges in the field of Social Work.
Keywords: Social Determinants of Health, SDOH, social work, social workers,
organizational change, social health needs, social needs, medical social work, SDOH
Implementation Manual, healthcare change.

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Acknowledgements
This capstone would not be possible without the generous support of Kaiser Permanente
with regional project SDOH Lead Samantha Delehant. Also, social workers and SW Managers -
especially the SDOH Human Centered Design Team (Carol McMenamy, Debbie Viera, Dianna
Sloves, Iris DeYoung, Jordan Simo, Maggie Marshall, Malikea Walker, and Martha Holland),
Nurses, and PCCs who identify SDOH needs. Thanks to Gail Sims and Danielle Brenes, COC
Dept Managers for all of your support. Special thanks to the KP Epic Build Team including Ann
Wolff and Soleil Flores, and Ella Vallejo who expertly and patiently guided the build and
allowed me to collaborate with them and the SW Manager team, iterating to strengthen the build,
collaborating to develop educational tools, and so much more. And thank you in advance to
Marco Nardin, data analyst, whose work has just begun.
A very special thanks to my wonderful Capstone Committee. Dr. Robin Kay-Wicker,
committee chair, whose gentle guidance helped me like a lighthouse through rough waters,
incredible thought partner Dr. Sara Schwarz, and Julie Abbott, LCSW, subject matter expert who
helped to open doors, and provided hours of input, encouragement, and opportunities.
Thanks to my fellow DSW students - especially Jessie Shay, Gregory Gomez, Joann Hall,
Lei Caine, and Aisha Wahab, who listened and sparked ideas. Thanks to my foils, Ann Reppun
and June Holte, and most special thank you to my sisters, Sharon and Joanne Vosmek, and my
mother Barbara Shaklan – these women all inspire me, read papers at all hours, and encourage
me in so many ways. Finally, my kids Jahlise, Alexandre, Ember, and Aundré, who put up with
wild dinnertime discussions about social justice issues, and who encouraged me completely.
Finally, my stalwart husband Timothy Park who was my resident computer guru, graphic
designer, and editor extraordinaire, I owe you ½ of this degree and very many vegan dinners.

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Positionality Statement
I was born into a non-traditional family of medical missionaries. My parents served in
Ethiopia, Thailand, and Honduras during times of crisis. Following in their footsteps I have
worked as a social worker helping people in need in a variety of medical settings (hospital,
nephrology, home health, hospice, rehabilitation, and mental health) and places including rural
Arkansas, and the city and county of San Francisco during the AIDS epidemic. Connections with
community and social justice have been central components of my work and my life.
I am passionate about improving the lives of those most affected by disparities and
inequities in our society. I became interested in the SDOH movement due to a passion to
increase health equity. CMS has figured out what medical social workers have known for years -
- that people living in impoverished circumstances have fewer chances to be healthy than those
living with wealth. In fact, 80-90% of health outcomes are due to health disparities related to a
person’s social circumstances. I am hoping to use this capstone project to improve the lives of
those most at risk, and to shed light through data collection, about the areas where we still have
work to do to create more equity in healthcare.
A bias that I have is that it is better to understand a person’s need than to pretend that
they don’t have need. One social worker asked me if it strips dignity from clients, when we
discover they have need and “cannot do anything about it.” I counter that even though I cannot
cure cancer, I still sit with my clients, helping them cope with and understand their situation –
and that this is a valuable, skillful act.
Assumptions that I make include trusting in CMS and others to use the data that we
collect for good. I am an eternal optimist and have used this to make things happen. In the last
decade there are two experiences where my optimism contributed to positive change. The first

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incident was when three hospitals and the county health department coalesced to create a medical
respite program in Marin. Homeless and marginally housed folks could have food and a
handicapped accessible apartment during a convalescing period while they receive IV antibiotics
or wound care, and in one case, even hospice services. The coalition succeeded and a decade
later the “Transition to Wellness” program is running strong with ongoing community support.
The second opportunity was during COVID. I realized that our hospital would be flooded with
patients from congregate settings and formed a team which reached out to all KP facility patients
to ascertain their wishes should they get COVID. We provided treatment in situ when there were
outbreaks in facilities, bringing only patients into hospital who wanted hospitalization, and
providing hospice and physician support for those who wanted to remain at home.
I am hopeful. Realistic about the barriers and challenges that we face but undaunted by
this wicked task. We should, can, and will help to create more healthcare equity by identifying
and serving patients with social health needs.

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Problem of Practice and Literature Review
According to the Joint Commission, The Social Determinants of Health (SDOH) account
for 80-90% of modifiable contributors to health outcomes (Peretz, et al, 2023, p.48). Because of
this, the Joint Commission along with Centers for Medicare and Medi-Cal services (CMS) are
mandating that accredited hospitals and health systems screen for SDOH in five domains: Food
Insecurity, Housing Insecurity, Utility Needs, Transportation Needs, and Home Safety (violence
or abuse in the home). Kaiser Permanents Northern California (KP NCAL) is designing new
systems for identification of SDOH. This capstone project supports the rollout of this initiative
by providing training and creating an Implementation Manual for social work managers.
The Department of Health and Human Services notes that disparities related to social and
demographic factors such as race, disability, sexual orientation, disability, poverty, rural area,
and employment, among other factors can be tied to disparities in health outcomes such as
“infant and maternal mortality, heart disease, diabetes, hypertension, chronic illness, disability,
cancer, mental illness, substance abuse, and overall life expectancy” (p.2, Whitman, et al,
2022).Whitman distinguishes between a Health Related Social Need (HRSN) which is an
individual level need and Social Determinants of Health (SDOH) which are system factors
having to do with environmental structures (social and economic) that cause inequalities. This
capstone initially deals with both the individual health related social needs of individual patients
and will ultimately have the ability to affect the larger-scale social determinants of health.
One of the identified SDOH is food. Studies show that it makes sense to view food as
medicine as medically tailored meals can reduce mortality and decrease hospitalizations for
patients with diabetes and heart disease (Aubrey, 2022). Kaiser Permanente (KP) did a study to
show that providing medically tailored meals can assist people with Type II diabetes to lose

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weight and improve AIC, which also reduces medical costs. Three recent studies at Kaiser
showed that medically tailored meals decrease mortality and hospitalizations for heart failure.
Yet many KP clients live in food deserts or have difficulty accessing the services due to
ignorance, finances, or other barriers and social factors such as location of their housing.
Kaiser is using both technology and people to screen for SDOH. In 2022, 10,000 KP
members were surveyed, and 68% of the members had at least one social need, with 20% having
more than 3 “with financial strain, lack of social connection, food insecurity, and housing
instability identified as significant concerns” (Kaiser Permanente, 2023, p.3). This same study
linked SDOH to health, finding that if members had one SDOH need, they were six times more
likely to report fair or poor mental health, and three times more likely to report fair to poor
physical health.
For the past few years the federal government, recognizing the link between social
determinants and health, has begun to expand the services that could be provided to Medi-Cal
beneficiaries, who are among the lowest income members of society. Since December 2022 the
Federal Government has allowed states to use 1115 Medicaid Waiver funds to support nonmedical programs and interventions to support the needs of people with certain health-related
social needs, focusing mainly on the 5 categories that CMS has chosen to screen (Hinton, 2024).
In California the Cal-AIM program is an 1115 Waiver program that seeks to address social needs
of Medi-Cal recipients and includes Transitional Housing Services and Integrated Case
Management services for High Utilizers and high-risk individuals with complex needs (Figueroa,
2024). In 2019 the Utah Alliance for the Determinants of Health was formed by Intermittent
Healthcare and two community groups. This demonstration project screened more than 20,000
individuals and helped over 1800 with needs related to housing, utilities, food, violence, and

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transportation. They saw a 34% decrease in nonemergent use of the Emergency Department in 2
counties (NASDOH, 2023: Intermountain Health, 2023). Utah saw health benefits and cost
benefits in a short period of time and is continuing its work beyond the demonstration project.
The success of this and other similar projects nationwide has spurred CMS to mandate SDOH
screening beginning in 2024.
While much progress has been made in regulation and through demonstration projects,
what has been missing in this space is a whole-scale, systematic approach to assessing and
addressing the social determinants of health. The CMS Guidelines to assess for needs is the first
step in initiating more large-scale equity in healthcare. Large health systems must now find a
way to implement meaningful change in practice. This is not insignificant because it has the
potential to revolutionize culture, focus and work – much the same way that introducing
electronic health records did with technology. This work will need to be done by individual
social workers (micro level) in a system or institution (mezzo) and community level (mezzo)
which has the potential to impact the health of the nation (macro).
After assessing the needs of individual patients, the next step or phase in the process will
include collaboration with community resources at the facility or local level to meet the
aggregate needs or challenges of patients on the community level (mezzo level), similar to
Utah’s demonstration project. The final step or phase will be to address society’s needs through
large-scale changes such as changes to insurance benefits and other national programs. America
lacks a comprehensive response to help people who struggle with access issues and inequities
regarding their health. Though 1115 Waiver programs are an effort by the Federal Government
to address SDOH there are still many gaps in the system. Only a handful of states (19) currently
participate in Waiver programs with additional states awaiting waiver approval. Ten states have

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not adopted the Medicaid eligibility expansion to 138% of poverty level, thereby increasing
disparity in access to care and leaving potentially eligible beneficiaries without resources
(Neukam, S. March 23, 2023). This state-by-state approach is not a solid national approach to
address the issues. That is still needed. Hopefully the data being collected by the new mandate
will be the first step in analyzing the problem, so that future solutions can be found.
This capstone project is designed to fill a unique void in the solution landscape. It is
designed to help ensure successful implementation of large-scale change in a healthcare system
by identifying and overcoming challenges and barriers to implementation and establishing the
groundwork for efforts to come in identifying community needs and national initiatives. By
doing this work, this capstone can provide guidance and support for smaller healthcare
institutions and areas of the country that are not early adopters of these efforts, who might
benefit from seeing successful implementation at another healthcare institution. All of this work
will ultimately help to “Close the Health Gap” in America - one of the 13 Grand Challenges
taken up by the social work profession and be part of an effort to create a more Just Society –
one of the main aims of the Challenges movement.
Conceptual/Theoretical Framework
Framework: Maslow’s hierarchy of needs
One of the fundamental social principles regarding the SDOH is best described by
Maslow’s hierarchy of needs (Mcleod, 2024). The pictorial representation of the hierarchy of
needs shows that basic needs must be met before individuals can begin to address higher level
needs. The assumption is that one would have more difficulty meeting the needs like Health
without first achieving many of the more basics needs described on the bottom tier. The SDOH

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are items that would appear on the bottom tiers – things like food, shelter, safety, and
transportation (Maslow, 1943).
quizlet.com
Social Workers have long been involved in helping to change people's lives by
connecting clients with resources. It is one of the fundamental tasks in social work. Systems
theory and the ability to leverage resources to serve our clients is a framework that helps us to
“understand and address the complex dynamics of human behavior and social systems”
(Bouchrika, 2024). Helping achieve equity in healthcare by connecting people with needed
services to improve their health is in alignment with social workers’ values. Social Justice and
Service are two of the values codified in the NASW Code of Ethics (Workers, 2017). The
identification of SDOH is in line with both of these values.
In future phases of this capstone, three of Bronfenbrenner’s ecological system of five
socio-economic levels: micro-, meso-, and macro- system levels will be addressed. On the
micro level, individuals’ needs will be assessed and addressed. Data collected on a community
level will enable determination of which particular resources may be missing or needed in a
facility (e.g., KP San Rafael hospital) or area (e.g., Marin/Sonoma Counties). Finally, on the

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macro level, Kaiser can use data on identified needs to direct community benefit funds in order
to alleviate gaps that contribute to the health burden experienced by many members of society.
Theory of Change
A theory of organizational change applicable to the capstone project is Kotter’s processfocused 8 step model. In this model Kotter lays out the following elements for creating change:
“1) Create a sense of urgency; 2) Build a guiding coalition; 3) Form a strategic vision; 4) Enlist a
volunteer army/Communicate the vision; 5) Enable action by removing barriers; Empower
others; 6) Generate short term wins; 7) Sustain acceleration; and finally, 8) Institute change”
(Kotter, 2020, p.9). This model applies to the change involved in bringing SDOH into the
healthcare world. This capstone’s focus is on steps 1-4 of Kotter’s model (Kotter, 2020).
A second model to combine with the process model above, is the people-focused model
by Virginia Satir that indicates that the people involved in change, in this case social workers, go
through several steps that affect performance over time. These steps include 1) The late status
quo and then the introduction of a foreign element (in this case, SDOH screening); 2) Resistance;
followed by 3) Chaos – where transforming ideas can be introduced; then 4) Integration; and
finally, 5) the New Status Quo (Strider & Strider, 2019). This model is closely aligned with the
processes involved in the new SDOH screening and assessment. In the User Journey Map
(Appendix F) four types of resistance or challenges to screening implementation were observed
during training and are described along with the commensurate feelings of the end user (social
worker) and possible solutions. An implementation manual (Appendix I) was developed to help
guide social workers and their managers as they navigate new systems to identify social
determinants of health within their healthcare settings.

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Methodology
Design Thinking
The high-fidelity prototype for the SDOH Capstone Project is a series of educational and
listening sessions and an Implementation Manual for Social Work Managers designed to elicit
greater responsiveness by the social workers in the completion of the SDOH screening. This will
ultimately create greater equity in healthcare by helping social workers accurately identify which
of the five domains patients are struggling with and assisting with those needs: Food Insecurity;
Housing Insecurity; Utility Help; Transportation Needs; and Safety. The Implementation Manual
was developed to give managers the information needed to spread this new practice and increase
buy-in for SDOH screening. It contains all of the elements – the What, the How, and
importantly, the Why a change in workflow is needed. The objective of the manual is to identify
barriers to implementation and work with stakeholders to remove those barriers to ensure
successful implementation of this important equity goal.
Design thinking methods were used to involve stakeholders – especially end users, in this
case social workers, in the design process (Liedtka, et al, 2011). The implementation manual
was iterated multiple times after getting input from social workers during 35 one-hour trainingand listening sessions in a three month period. Additionally, the design team associated with this
capstone facilitated weekly meetings with social work managers and the design builders for a
period of five months. Most recently, the SDOH implementation group has also had a chance to
have input from the Regional Program and Build Team regarding the Implementation Manual.
They had very few recommendations – the most significant being the terminology used to frame
the problems and challenges faced by social workers. This recommendation was also shared by
the committee chair. They favor the use of terminology “problems and challenges” over terms

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like “resistance” faced by social workers, which is the word posed by the change process
theoreticians in this capstone. Modifications were made to the implementation manual to reflect
these recommendations.
Design Justice Principles
When Kaiser started the journey to create new systems to integrate SDOH screening in
early to mid-2023 they had a design team that did not include either the end user or the
population that they served. They were not adhering to principles of design justice which
recommends that we “center the voices of those who are directly impacted by the outcomes of
the design process” (Design Justice Network, 2018, p.1). As part of this capstone project the
team began to integrate the voices of both the social work managers and the social workers
themselves (end users) into the design -- iterating the new system, platform, and process multiple
times in an effort to incorporate their voices and ideas.
Social workers were very concerned about how the change would affect the therapeutic
relationship between social workers and their patients, and the impact that opening wounds or
acknowledging vulnerabilities might have on patients, especially related to safety, one of the
SDOH domains. Once the social work teams were involved there was greater adherence to
Design Justice Principle #3 - “prioritize design’s impact on the community” (Design Justice
Network, 2018, p.1) as social workers considered the impact of the new SDOH process on the
beneficiary. More specifically, social workers moved beyond solely considering equity
(intended as the goal of the screening) to consider how the process of asking intrusive questions
would potentially impact the patient in the moment and the relationship between the social
worker and the patient.

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Finally, although possessing technical expertise in the area of SDOH, the lead in this
project assumed the role of facilitator, eliciting the opinions and voices of the end users. This
input was conveyed to the design group in a continuous feedback loop. This process is an
example of another principle of design justice, “designer as facilitator rather than expert”
(Design Justice Network, 2018, p.1).
Market Analysis
There is already an expressed demand for the Implementation Manual associated with
this project. A local hospital reached out to see how KP San Rafael was dealing with the new
CMS Guidelines and the draft manual was shared in effort to assist this non-profit organization
in meeting goals around the new SDOH measure. The SDOH design team has plans to publish
the findings of the project, and there are plans to spread this best practice both within and outside
of Kaiser through the Institute for Healthcare Improvement (IHI) or other conferences in the
coming year. Thousands of healthcare entities throughout the nation will need guidance and
support to implement the SDOH Best Practices mandated by CMS so there is a large potential
audience for this project. See Appendix A for Marketing tools associated with this project.
Project Description
In 2022 CMS mandated that all Medicare- and Medicaid-funded healthcare institutions
screen for SDOH among members served and provide data about SDOH’s identified as early as
January of 2024. In the future, health entities will be asked to describe efforts made to address
SDOHs within their healthcare system. KP NCAL Region began designing the structure for data
capture mid-2023. This was completed in December 2023, and rolled out to social workers in
January of 2024, with data collection beginning February 2024. While social workers have
always done screening of some identified patients for social needs, the institution did not have a

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systematic way of screening all patients, in all five domains, and capturing information about the
population in the healthcare system. This capstone was created to identify and address concerns,
barriers, resistance, and challenges faced by social workers during the rollout of the new
screening assessment, and to collect and disseminate tools to assist them with these challenges.
This will promote Kaiser’s ability to get accurate data and meet the SDOH needs of patients
more efficiently and effectively.
Until now, social workers have relied upon physicians and nurses to discover social
issues through their interactions with patients and refer to social workers to follow up with
patients regarding their specific needs. The current system did not have any specific goals
regarding social health needs and no way to measure the effectiveness of their interventions. The
goal was individual assistance as opposed to the broader goal of health equity. Until now there
were few measurements and little data regarding who is being helped with which health related
social needs (HRSN). The new systematic screening of SDOH uses evidence-based questions to
screen every hospitalized patient for social needs in five domains: food, housing, utilities,
transportation, and safety. The first level screening will be done by nurses (floor nurses and
Patient Care Coordinators/ Case Managers) who see every patient. Positive responses will be
sent to social workers for more in-depth screening and to assist patients with their unmet needs.
The goal of this is to identify those with SDOH needs and to provide these individuals with
services that address those needs. This new screening allows systematic identification of patients
at risk and should lead to greater equity which is the goal of CMS and The Joint Commission.
The first level screening questions asked by nursing revolve around patient safety or
identification of abuse at home, and housing stability. If these screening questions are positive a
referral is made to social workers. The Patient Care Coordinators, otherwise known as RN

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discharge planners, ask the other three validated screening questions: Question 1) “How hard is
it for you to pay for the very basics like food, housing, medical care and heating?” If the patient
chooses Hard or Very Hard the referral will go to social worker for second level of screening.;
Question 2) “In the past 12 months, has lack of transportation kept you from medical
appointments or from getting medications?” A positive response sends the referral to social
work; and Question 3) "Would you like us to assist you in getting help with any of the
following:” if any of the five social determinants of health are chosen (food, transportation,
housing, utilities, and safety) a referral will be made to social work for level two screening.
The level two screening by social work uses validated questions as recommended by
CMS (see Implementation Manual, Appendix I for details). The social worker then asks thirteen
mandatory questions to screen much more in-depth regarding these five domains. There is one
general question (re-asked by SW): How hard is it to pay for the very basic like food, housing,
medical care, and heating. Then they ask two questions regarding food insecurity: 1) “Within
the past 12 months, you worried that your food would run out before you got the money to buy
more,” and 2) “Within the past 12 months, the food you bought just didn’t last and you didn’t
have money to get more.” The next two questions center around transportation barriers: 1) “In
the past 12 months, has lack of transportation kept you from medical appoints or from getting
medications?” and 2) “In the past 12 months, has lack of transportation kept you from meetings,
work, or from getting things needed for daily living?” The next four questions center around
housing insecurity: 1)“In the last 12 months, was there a time when you were not able to pay the
mortgage or rent on time?”; 2) “In the last 12 months, how many places have you lived?”; 3) “In
the last 12 months, was there a time when you did not have a steady place to sleep or slept in a
shelter (including now)?” and the final housing question, 4) “Think about the place where you

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live, do you have problems with any of the following? – the multiple choice answer includes:
pests such as bugs, ants or mice; mold; lead paint; lack of heat; oven or stove not working;
smoke detectors missing or not working; water leaks; none of the above; or prefer not to
answer.” Finally, there are four questions that speak to patient safety. They were derived from a
survey regarding interpersonal violence, but as a result of feedback from the end users the
regional and national team are considering broadening the questions to include safety regarding
any caregivers as well as partner. The four questions are: 1) “Within the last year, have you
been afraid of your partner or ex-partner?”; 2) “Within the last year, have you been humiliated or
emotionally abused in other ways by your partner or ex-partner?”; 3) Within the last year, have
you been kicked, hit, slapped, or otherwise physically hurt by your partner or ex-partner?”; and
4) “Within the last year, have you been raped or forced to have any kind of sexual activity by
your partner or ex-partner?” Given the rising tide of aging patients, the end users (social
workers) proposed adding the following: “or anyone who provides care for you?” to each of the
questions in this area. This recommendation has been taken back to the design team for a
decision. Social workers will aid patients with positive responses as resources are available.
The fundamental design principles described in Liedtka and Ogilvie’s book on
Innovation “Designing for Growth” (Liedtka & Ogilvie, 2011) apply to this particular project.
The authors postulate that there are three “fundamental design principles: Don’t let your
imagined constraints limit your possibilities; aim to connect deeply with those you serve; (and)
seek opportunities not perfection (p. 8). The goal was clear: screen every patient for SDOH
needs. Kaiser started from scratch and imagined how to accomplish this goal in a systematic
manner, by building all new assessments using a new part of the electronic health record (EPIC).

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The organization thereby demonstrated dedication to the determination not to let constraints limit
possibilities.
The constraints to the innovation solution seemed daunting at first. How will Kaiser
systematically screen every patient? Are there enough staff and resources to do justice to this
endeavor? How will the project use the tools in the Electronic Health Record (E.H.R.) to capture
the data that we need? How will Kaiser teach the 500 plus social workers to learn to use the new
EPIC screening tools? What are the resources available to help staff learn a new way of assessing
patients? The portion of the project that this capstone deals with centers around the social
workers’ ability to learn, adapt to, contribute to, and ultimately adopt and even own the new
screening process.
Connecting deeply with the social workers (end users) was enjoyable and fruitful. Using
human centered design and led by an experienced social worker, a series of trainings were
scheduled where the team not only provided information to the consumers (social workers) about
how to do the assessments and documentation, but also used these meetings as opportunities to
iterate - - as listening sessions with social workers and social work managers. In this way, the
capstone team was able to discover challenges, barriers, and needs of the workers performing
assessments and incorporate changes to the training to meet their needs. Listening deeply to the
end users (social workers and their managers) allowed the SDOH Team to incorporate ideas that
would be useful to the social workers in adopting the platform and creating buy-in in the process.
The third design principle, seek opportunities not perfection, occurred as multiple
iterations of the project included needs of the social workers. This was especially true when
iterating to include the addition of “the Why”. The group had left some fundamental items out of
initial training and social workers asked the question, “Why is it necessary to systematically

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screen for risk?” As a result, the team incorporated Maslow’s Hierarchy of needs and helped to
create urgency for the project (Kotter, 2020), tying it to what matters to the social workers: the
needs of their patients, and social justice. Sharing success stories regarding how screening in
other settings has helped to meet the SDOH needs of patients, the team iterated and strengthened
the training which was crucial for moving end users toward adoption. The team incorporated the
example of people with diabetes living in food deserts and the positive health outcomes
associated with providing healthy food. This helped to tie this project to the health of our
patients, enabling social workers to view this project as more than a requirement. Rather, this
approach enabled social workers to see real possibility for meaningful change in the lives of their
clients. At the same time the project was tied to the values and ethics of the social worker
profession, with an emphasis on three of the values: Service, Social Justice, and Competence
(NASW, 2021).
The second finding or iteration involved the unease that some of the social workers
expressed around asking difficult questions. Shadowing is a useful tool to assist with this, and
presenters incorporated demonstration as to how the workers might frame some of the difficult
questions. Resistance due to countertransference is called out in the Implementation Manual –
looking at our own issues often sheds light on the difficulties we face as social workers in asking
certain questions. National KP had excellent resources including a video that is especially useful
for newer social workers. These resources were shared regionally with social work managers,
and social work teams were shown where to find these resources during trainings. Meetings were
held with the Violence Prevention Task Force who mandated Intimate Partner Violence
questions in the outpatient medical setting in the past, to find out how they were successful at

21
approaching change around the difficult questions regarding abuse. Scripting was discussed as a
useful tool which was used at the time of this past mandate.
The third iteration focused around allowing patients to say no and dealing with feelings
of rejection. Some clients don’t want to answer questions in general, specifically around
normally taboo subjects - like discussing finances with strangers. As this is not an unfamiliar
experience for social workers, it was relatively simple to acknowledge and process the right of
patients to refuse help.
As a result of further listening, trainings were iterated to incorporate global information
about the potential for helping individuals (micro- level), as well as the eventual use of data to
help our communities (mezzo- or facility level). The facility data that will be captured (Mezzo
level) will be used to help focus collaboration with community partners to create resources where
they are lacking. Finally, listening to the questions posed to the design team led the team to
discuss the potential of this project to help entire social groups (Macro level). Kaiser can utilize
data to inform the use of community benefit funds and advocacy efforts at the state and federal
level, to benefit the health and well-being of all persons at risk.
One consideration raised by stakeholders pertained to asking assessment questions in the
potential absence of resources to address identified needs. While a significant issue,
identification of trends and themes will permit the development of resources that do not currently
exist, either through collaboration with local community-based organizations or the dedication of
resources such as Kaiser community benefit funds to expend on solutions. Finally, the process
of listening to patients that want to convey their needs and concerns may have therapeutic value
– even in the absence of resources to solve the problem.

22
Another potential ethical issue raised by the social workers is the possibility of
traumatization or re-traumatization of patients. This is especially true around questions related to
safety and violence. Long ago it was discovered that the risk of not asking outweighs the risk of
asking about these risks and vulnerabilities – and many states have created laws around reporting
requirements as a result of years of study regarding these ethical considerations (Thomas &
Reeves, 2024).
The Katie Perma Nettie Journey Map (Appendix F) illustrates some of the challenges that
were discovered through various iterations. Each of the discoveries noted was seen as a new
opportunity to iterate and better serve the users. The end result will benefit the users of the new
platform (Social Workers) and ultimately will help Kaiser patients as their needs are met, and
their health and wellness improve. This equity initiative ties directly into the Grand Challenge
“Close the Health Gap” as well as the larger Just Society goals, enhancing equity in the
healthcare field. Pilot projects throughout the US are demonstrating positive health and wellbeing outcomes for patients screened for SDOH (Perez, 2024). It is expected that this project
will change the status quo and enhance efforts to improve the condition of Kaiser patients who
have SDOH needs.
The capstone prototype associated with this paper is an Implementation Manual. Using
the information and iterations discovered during over 35+ trainings and meetings with frontline
users (social workers and social work managers), a step-by-step guide was developed. Designed
for use by Social Work Managers in the Northern California Region of Kaiser Permanente, this
manual provides a useful map to guide social workers through the process of understanding
SDOH – the Who, What, Where, When, How, and Why. A copy of the Prototype can be found in
Appendix H.

23
Implementation Plan
More than 35 one-hour training and listening sessions were completed, and a web-based
educational module was developed by this capstone work group. The “Implementation Manual
for Social Work Managers” was completed and made available to KP NCAL Region Mangers
and to the Regional Task Force in March. Both groups have had an opportunity to provide input
and an electronic version of the next iteration of the Manual was sent in May of 2024.
This project capitalizes on opportunities for dissemination of the lessons learned and
reflected in the implementation manual. Within a week of its introduction at the Regional Level a
local (non-KP) hospital reached out to KP leaders to ask about how the CMS regulations around
SDOH were being addressed. The Draft Implementation Manual was sent to them in an effort to
share knowledge, learnings, and best practices. Kaiser leadership from the Regional SDOH Task
Force has asked to have the manual and paper published in order to spread the word as well. And
finally, sharing information about SDOH implementation at conferences will be another way to
assist in the promotion of this initiative. In order to spread information concerning the findings
and best practices the team has built a Marketing Plan. This plan will employ graphics currently
used in the Implementation Manual. An example of a speaker bio and marketing flyer is
attached in Appendix A for reference.
Kaiser has assumed full financial obligation for the project. An implementation and first
year budget plan have been developed (see Appendix E: Implementation Budget and Funding
Plan for Year One) which can be presented to NCAL Kaiser for consideration. The main
presenter will be paid as usual out of her salary (with many hours donated) so most of the costs
will be related to travel and accommodation at conferences to spread the capstone project and
findings.

24
Evaluation Plan
Measuring Social Change/Impact
The SDOH project has already begun to collect output data measuring adherence to the
new protocol (screening), which is the current CMS requirement. There is an adherence rate for
Level I Screen with a goal set at 90% across the Region by August 1st. In San Rafael the Patient
Care Coordinators/RN Case Managers and bedside RNs are screening in all 5 of the domains and
in May completed the Level I Screen at a rate of 80% or higher. The level 2 Screen by social
workers has had a slower and rougher start. There are many more questions that must be
completed for adherence (13 as opposed to the 5 screening questions by RNs and PCCs) and to
get credit for screening social workers must ask all 13 questions. The social workers in San
Rafael were over 80% adherence in early May, then dropped below this level as new social
workers onboarded in May and June. Soon, individual level data will be available for managers
so that they can see which workers are having difficulty completing the screening. It is
anticipated that the Implementation Manual will be helpful to managers as they coach their teams
to increase adherence.
These output results (% completion) will be shared either monthly or quarterly with
CMS, and at any audit or visit by CMS and the Joint Commission this next year and beyond.
They will be shared weekly with the Department Managers who can use this information to
increase adherence. The first set of data was sent to managers the week of 5/14/2024, and the
plan is to send data weekly reports that will include adherence for the past week, 2 weeks and
past month. Managers can also go to the SDOH Share Point site to pull data by setting their own
parameters (by time frames, SDOH domain, etc.) at any time starting 5/14/2024.

25
The next step regarding data collection will be to define health outcomes that might be
related to the SDOH, and to create a way to mine outcome data for patients who had a positive
assessment and received an intervention. A mixture of surveys and data mining is being
considered that will link SDOH implementation with health status as measured by diabetes
health (e.g., HgA1C), heart health (e.g., lower BP), and adherence to medication regimens
(frequency of refill), which can be obtained through the KP database. Research can compare
patients with a positive screen who received assistance compared to those that did not receive
help, or they can look at longitudinal data on patients to see if the individual patient’s health has
improved since a social intervention occurred. KP has teams of professional analysts with
expertise in population-based data collection whose job is to mine the organization’s vast
databases for information.
At a recent convening of Care Delivery Social Health Implementation Partnership (CShip) the North Carolina Medi-Cal demonstration project shared early findings of their SDOH
data including participant survey results. The project developers discussed the benefits of SDOH
screening in three domains - food, housing, and transportation. In addition to noting health
benefits and cost reduction such as reduction in ED utilization as outcome measurements, the
research team reported that patients who were screened and assisted also reported feeling happier
as a result of screening and assistance (Perez, 2024). Success of this and similar demonstration
projects paved the way for the current CMS mandate.
The other way that data can be used is to analyze if there are patterns of need in a
community. For instance, if patients in a specified geographical area such as a Kaiser facility
determine that patients over 75 years of age are having difficulty with transportation, managers

26
are empowered with this data to collaborate with transportation agencies to better meet the needs
of this particular population.
The Coordination of Care Department (Discharge Planning and Social Work) will report
SDOH data to the facility through various committees including Quality and Compliance;
Medical Executive Committee; and the Resource Management Operations Committee (RMOC).
These committees will be responsible for compliance with the CMS mandate, making
suggestions for the use of the findings, adherence to goals developed around SDOH, and ideas
for future data gathering.
The findings include the many barriers to implementation expressed by end-users –
primarily in four different areas: 1) their lack of understanding about the reason for and
importance of this initiative; 2) their discomfort in asking difficult questions and use of evidencebased questions; 3) their concerns and feelings related to unease of patients answering the survey
questions; 4) their concerns and feelings in relation to the lack of services available to assist
patients at the time of the screening.
Initial data from the project demonstrates the importance of the manager’s understanding
of and involvement in key elements of the manual. The managers with the most active
engagement and input – including participation and giving feedback about the manual also have
the most output from their teams as demonstrated by the blue boxes in the middle section
(columns 5 -9) of the chart below. The managers at Kaiser’s facilities in San Rafael, Stockton/
Modesto/ Manteca, and Antioch have spent the most time developing and iterating the
implementation plan. Not surprisingly, these are the teams with the highest rate of successful
screening as indicated by higher percentages of screening completion (blue color) on the chart
below. The facilities that have had education (instruction directed by the Implementation

27
Manual) provided by the facilitator have some successful screening (as indicated by the low
percent of completion - orange below) and facilities that either lack a social work manager,
and/or lack staff training regarding the implementation of the SDOH elements show the least
screening (as shown by their low or 0 values on the chart below – no color).
The next step is to assist the social work managers who have not yet adopted the
Implementation Manual to understand the importance of the project and utilize the manual.
Future instruction will be provided for social workers at facilities that are not yet achieving
screenings at 70% or greater (goal by end of May). By the end of August, the plan is to have all
facilities providing Level I and Level II screening at the 90% level.
One further level of research that involves social work adherence and understanding
could include a survey to social workers prior to training and after (pre- and post-test) which
might assess their knowledge concerning SDOH (the what), their willingness to engage in

28
activities (the why) around SDOH matters, and their knowledge of processes for screening (the
how). A sample questionnaire is included in Appendix H.
Challenges/Limitations
This capstone focused on discovering and mitigating barriers experienced by social
workers during the implementation phase of this transformational innovation in healthcare.
Healthcare entities like Kaiser are incorporating social health into their plan for health equity for
the first time in a systematic way, with the ability to capture data. This is a new era in healthcare
and presents opportunities for social worker leadership in healthcare. It will be useful to tap into
the expertise of social workers and public health innovators in the years to come as they explore
how to best meet the needs of patients with social problems large and small. Collaborations and
systems approaches are areas of expertise for social work so it makes sense to continue to
involve social work in the innovation space.
One potential limiting factor may be the shortage of social workers (Kastner, 2019) and
the need to train more social workers. Some managers anticipate needing as many as 20% more
social workers (Viera, 2024) to meet the needs of patients for screening of risk and interventions
for those at risk, which requires additional time. There is also a threat to social work and
potential for union backlash as much of this demand in other areas of the country has been met
by hiring non-professional and non-social work employees who are frequently referred to in the
literature as Healthcare Workers (HCWs). Another challenge will be keeping momentum for this
project once it is seen as standard practice or standard work. Right now, there are funding
streams from Federal and State Grants to study this issue. However, it is unknown what will
happen when those funds dry up. Will healthcare entities be responsible for meeting the social

29
needs of patients? What are the policy implications for government entities? These questions
have yet to be addressed.
One limitation of this project is that it does not account for many other SDOH’s
suggested in other models such as social isolation, employment (Kreuter, 2022), and childcare or
adult day care. These will need to be considered in the next round of iterations. For example, it
could be true that social isolation is more problematic for patients in one area, facility, or region
than one of the five chosen SDOHs. While choosing the same SDOH for all facilities does help
to control the variables of this social health experiment; opportunities to collect information and
provide support to our patients in other areas may be missed. There will continue to be iterations
to the model, and input from our end-user stakeholders should be considered carefully as the
process is refined. Social workers should be encouraged to write in missing SDOH’s so that
results can be gathered for future iterations of the model.
Conclusion and Implications
The SDOH project, and in particular helping social workers adopt this work is extremely
important when considering health equity in this country. Early results from demonstration
projects show that this work has financial value and value in terms of creating health and wellbeing for patients (Artiga, 2018; Aubrey, 2022; Hinton,2024; Perez, 2024; Perez, Kimberg, &
McDonald, 2022; Intermountain Health, 2023; Kreuter, 2021).
The lessons learned revolve around the Design Thinking and Design Justice Principles. It
is important to involve the end users in the process as close to the inception of the project as
possible. The theories used in the project helped to inform the project and have added value in
an area that is innovative – namely identifying and remedying challenges and barriers to
implementation. The identification of ideas to enhance implementation were discovered by

30
listening to end users and included in the Manual. The application of design principles to this
problem is innovative and adds value to the field of social work.
Finally, if implementation goes smoothly, data should soon be available that will inform
the next phases of the project – the mezzo and macro level phases, identifying SDOH needs in
the population and collaborating with community-based programs to help our facilities and KP
members. The next five to ten years of this equity challenge will be spent analyzing data and
deciding the next steps toward Closing the Health Gap.

31
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Appendix A Marketing and Presentation Tools (primarily for Conferences & Training)
The Road to Equity in Healthcare: The Social Determinants of Health

37
Appendix Marketing Tool (continued)

38
Appendix A Marketing Tool for Conferences (continued)
Speaker Bio
Ruth A. Vosmek, MSW, LCSW, DSW
With over 30 years’ experience in healthcare including
hospital-based care, home health and hospice, nephrology and
psychiatry, Ruth Vosmek is known for exploring individual and
systemic answers to issues and problems of the day. Her
experience starting an interdisciplinary collaborative task force
during COVID led to better understanding of patients’ wishes
and helped to identify patients who wished to be helped in
their home environment with support during COVID. This led
to more appropriate utilization of hospice and hospital-based
services, helping to better serve both the hospital and
community.
This past year Dr. Vosmek has immersed herself in the work of healthcare equity by providing
training and education around the new CMS Mandate regarding screening for the Social
Determinants of Health (SDOH) to over 400 individual social workers in a large healthcare
system (Kaiser Northern California) and creating an Implementation Manual for Social Work
Managers. She is committed to the idea that we can make movement to close the health gap
for persons experiencing problems related to the SDOH. Her vision is to help make this
systemized approach to screening more accessible to workers by explaining the What, the Why,
the Who, and the How – meeting social workers where they are and exploring barriers and
challenges to meeting the goals set by CMS and The Joint Commission. She worked with a
Regional Team that established workflows and systems designed to meet this challenge and
listening to end-users (social workers and social work managers) as stakeholders in this
important work.

39
Appendix B
Design Brief: Social Determinants of Health (SDoH)
Screening and Assessment in Kaiser Northern California
By Ruth Vosmek, LCSW (DSW Candidate)
Project
Description
What is the business problem or opportunity?
Describe the project in a few sentences, as you would in an “elevator pitch”.
Social Determinants of Health (SDoH) account for 80-90% of modifiable contributors
to health outcomes. The Joint Commission and CMS are mandating that hospitals
and healthcare systems identify and address the identified SDOH. Kaiser NCAL is
creating new systems for identification of SDOH. This project will help the NCAL
Region design, train, and modify these new tools. We will then analyze early results
of screening and provide a risk profile associated with each facility to the Social
Work Managers, and work with the managers to create strategies specific to the
needs of their population. Finally, develop and send “patient messaging” around
each SDoH with local resources attached.
Intent
Scope
What is within the scope of the project and what is outside it?
Inside scope: training staff on new tools; feedback from teams about what’s
working; analysis of data; product for SW Managers in each facility that shows
where to focus initial efforts (low hanging fruit) and where to focus longer term
efforts. Share strategies between facilities.
What efforts sit adjacent to this particular project? creating new assessment tools
Exploration
Questions
What key questions will you need to answer through your research?
1. Are we looking at the correct 5 measures? Does anything else stand
out?
2. Do we have the staff we need to do the assessments? What other
resources do we have outside the hospital to assist?
3. What needs to be done by nursing? PCCs? Social Workers?
4. Where are the gaps in care in each community?
5. How can we leverage technology (Thrive Local and patient messaging
systems)?
6. How will we know the change has had a positive effect on health
outcomes?
These may include customer needs to understand better, emerging technical
possibilities, and new business models.
Target
Users
Who are you designing for?
1. First Level Screeners (PCCs, nursing)
2. Second Level Screeners & Resource Providers: Social Workers

40
3. Patients (beneficiaries)
4. Community systems
Try to be as specific as possible. Who do you need to understand? Why are they
important?
1. Patients are at the center of this project. First and foremost, we need to
understand what they need.
Research
Plan
How will you explore your opportunity space?
1. I will read as much of the research as I can around the chosen SDoH.
2. I will speak to the Regional Design Team.
You will need a plan, including a timetable and milestones, for both primary and
secondary research.
See GANTT Chart
Expected
Outcomes
What outcomes would you like to see?
1. Staff trained in assessment tools by 2/10/2023.
2. Staff satisfied that we are making improvements in our patients’ lives.
3. Patients better connected to resources related to SDoH and better able
to ask for help regarding any psychosocial issues impacting their health
and well-being.
Success
Metrics
How will you measure success?
1. Number of patients newly identified. (process measure)
2. Number of services or resources provided. (process measure)
3. Increased patient health. (outcome measure)
Project
Planning
What resources to you need? Why? At what stages?
1. Time, Time, Time – TIME!
2. PCC Staffing during training and implementation of screening.
3. Staffing during training and implementation of new P/S assessment.
4. Likely SW staffing increase due to increased work load
5. iPads at bedside may be useful. Unsure – TBD.
What is creating the time urgency? What is the relevant timeframe for fulfilling the
brief?
There is urgency as there are federal mandates for implementation (February). The
Social Work Team (Managers) found out about this in the fall, and Region has been
building tools in HealthConnect. These should be ready by 1/10 and we have one
month until implementation is expected (2/10). First reporting to CMS and Joint
Commission happens in April.

41
APPENDIX C
DESIGN CRITERIA: Social Determinants of Health (SDOH) Screening by Social Workers at Kaiser NCAL
The design criteria captures the conclusions from the What is stage and provides the criteria by which
possible solutions will be evaluated. It is intended to focus on the attributes of an ideal solution or
portfolio of solutions. Overall, the design criteria distills what you’ve learned from your research and
interviews as well as the insights revealed from the work of your design team.
Answer the questions below to help you generate a concise team design criteria.
Design Goal • What have you learned about the target
population?
• What needs (functional, emotional,
psychological, social) does the design have to
fulfill for the target population?
• What is strategically important to address
those needs?
• Target Population: Social Workers
• Beneficiaries – pt’s with SDOH
needs
• See Katie Nettie P Journey Map
• Barriers and challenges faced by
SWers
User
Perceptions
• How important is your proposed
offering to the target population’s wellbeing?
• What does ease of use mean for the
targeted population?
• Very important for pt’s – health
improvements have been established
as outcome data
• Ease for SWers – means that we listen
to their ideas and incorporate their
suggestions (means the difference
between ignoring needs and fulfilling
needs)
Physical
Attributes
• Must the solution (e.g., service,
product) be able to capture, store,
and/or transmit information about
usage
• Doe the solution need to be designed
for use in specific environment or
situation
• Are there bandwidth and connectivity
issues?
• Yes
• Yes – hospital, captured in HER
• Requires computer – should have
“code dark” backup (hard copies of
questions)
Functional
Attributes
• Does the design need to accommodate
specific user-case scenarios?
• Does the design need to address
compatibility or standard issues
• Training will be required for all new
staff
• Standardization will be important for
accuracy of data
Constraints • What constraints does the sector
and/or environment impose?
• Are there ecosystem and regulatory
concerns?
• Not enough SWers to complete
assessments?
• Must be adherent to CMS regs
Adapted from D4G pp 206-207

42
Appendix D
LOGIC MODEL
*********************************************************************************************************************
NAME OF PROGRAM/PROJECT:
Social Determinants of Health (SDoH)
SITUATION: 80%-90% of modifiable contributors to health outcomes are related to SDoHs. CMS and Joint Commission are implementing guidelines for
screening and service provision within healthcare settings.
PRIORITIES: Training for rapid implementation of Innovative solution to equity problem: Screening, Analysis, and Connecting Patients to Resources
INPUTS
OUTPUTS OUTCOMES
Activities Participants Short-term Medium-term Long-term
Staff
Time
Infrastructure (IT build)
Analysis
Technology
Train staff on new
screening tools
SWers Conduct SDOH
assessments with
patients
Refer Patients to
existing services
Gap Analysis
PCCs and Nursing
Social Workers
Everyone
Build Team
Increase identification
of challenges, barriers,
& resistance to
implementation by
social workers
Identify solutions and
strategies to cope with
for above challenges
Awareness of extent of
pt needs broken down
by facility
Connections to
community partners
Change in practices and
values around patient
p/s social needs related
to medical issues
Increasing
understanding of pt p/s
needs
Patients will be better
connected with services
needed in 5 identified
areas:
*Food insecurity
*Housing insecurity
*Transportation
*Interpersonal safety
*Utilities/ finances
Patient health will
improve as a result of
better connection to
resources in these 5
areas.

43
NAME OF PROGRAM/PROJECT:
Discover services
missing from model
ASSUMPTIONS EXTERNAL FACTORS
1. We have resources to plug patients into (especially housing)
2. Social Workers can meet increased demand on their time
3. Findings from other areas of the country will apply to N. California
1. Finances / resources in the community
2. Federal, local, and state funding for resources (especially housing)
3. Are there enough social workers?
EVALUATION PLAN:
Work with Regional Analysts to prepare analysis of data. Are we looking at the correct 5 items? Provide information to facility SW Managers based on new
assessments.

44
Appendix E Budget
NA1:E50CAL Kaiser Regional SDOH Project Implementation
Fiscal Year 2024
Category Start Up Year 1 Comments
REVENUE
Trainer/Facilitator Trainings $14,320 $1,320
In Kind; Phase II Activities
(Collab)
SW Managers SW Manager Time $6,000 $6,000
In Kind; Phase II Activities
(Collab)
Social Workers Social Work Time $4,800 $8,000 In Kind
Graphic Artist Consultant $450 In Kind Graphic Artist
Comm & Mat'ls Manuals for Conferences $5,000 In Kind
Trng/Prof Dev $2,000 In Kind
Travel $5,000 In Kind
Office Supplies $500 In Kind
X______
Total REVENUE 38,070 15,320 CMS Mandate; KP Donation
EXPENSES
Personnel Exp
Wages/Salaries
Trainer/Facilitator 112 Hrs of Meetings / trainings $14,320 $1,320
$110/hr x 8 hrs w/Mgrs; 40 hrs
w/ SWers; 4 hrs Program; 60
hrs Development; 4 hrs Data;
Year 1: Quarterly Trainings 12
x 1 hr
SW Managers One 2-hr traing; 4 hrs Analysis $6,000 $6,000
$100/hr x 6 hrs x 14 Mgrs;
Phase II Activities first year

45
Social Workers One 1-hour training $4,800 $8,000
$80/hr x 1 x 600 Soc Wkers;
New Swers Training online 1 hr
x 100 new Employees
Sub-Total
Benefits (@ 30%)
Total Pers. Exp 25, 120 15,320
Other Operating Exp
Contractors (Indep) Graphic Artist $450 $0 $100/hr x 4 hrs + In Design $50
Occupancy/Rent N/A Use of KP Space
Furn & Eqpt N/A Use of KP Space
Tech/Computers N/A Use of KP Equipment
Tel/Utilities N/A Use of KP Space
Comm & Mat'ls Manuals for Conferences $5,000 $0
$50/manual x 100 = $5000 for
spread
Trng/Prof Dev Conferences x 4 $2,000 $0
$500/conf x 4 (salary &
entrance)
Travel Plane, Food, Hotel $5,000 $0 $1250/conf x 4 conferences
Prof Srvc's *
Office Supplies Paper, Ink $500 $0
X_______
X_______
X_______
Total Other Op Exp 12,950 0
Total EXPENSES $38,070 $15,320
$0 $0

46
APPENDIX F Insert User Journey Map: Katie Perma Netty’s Journey through SDOH Orientation

47
Appendix G Timeline

48
Appendix H SOCIAL WORK SAMPLE SURVEY
Knowledge Test – Pre and Post Assessment
Social Determinants of Health (SDOH)
Please take a moment to answer the 12 questions below so that we can see if our
training is effective. No one will track your individual results. The correct answers will
be sent to you immediately after taking the training and post test. We will look at the
aggregate (group) results in order to provide social workers with better education
around the SDOHs.
1. Social Determinants of Health (SDOH) are things or conditions in a person’s
social environment that might impact their health. True or
False
2. Which of the following are the SDOH Questions asked by our Patient Care
Coordinators (choose 3):
a. How hard is it for you to pay for the very basics like food, housing,
medical care, and heating?
b. How many people do you support in your household?
c. In the past 12 months, has lack of transportation kept you from
medical appoints or from getting medications?
d. Do you have a fire extinguisher in your home?
e. What is your income?
f. Would you like us to assist you in getting help with any of the following:
Caregiver/Placement; Child care; Employment; Finances; Food;
Housing; Internet access; Loneliness or social isolation; Possible
abuse or neglect; Transportation; Utilities
3. Items that used to be in my In Basket previously will now show up as a blue
bells in Admission Alert column on my daily work sheet. True or False
4. An Audit Score (for high alcohol use) will show up as a number in Admission
Alerts. I should follow up with SBIRT counseling and alert the physician if a
patient scores 16 or above. True or False

49
5. Circle the 5 SDOH Domains that Kaiser is screening for in 2024
a. Food
b. Transportation
c. Grandchildren
d. Social Isolation
e. Safety
f. Housing
g. Employment
h. Utilities
i. Tree Trimming Service
6. Rate the importance of screening for SDOHs (in your opinion – circle #)
Not important at all ---------Moderately important-------------Highly Important
1 2 3 4 5 6 7 8 9 10
7. Giving healthy meals to someone living in a food desert is an example of a good
intervention for someone living with diabetes. True or False
8. Maslow’s hierarchy of needs would say that it’s important to help people to
meet their most basic needs as that will affect their ability to stay healthy.
True or False
9. The National Association of Social Workers (NASW) speaks to our
involvement in the SDOH. True or False
10. My manager has resources for me if I need help with the SDOH. True or
False
11. I can find more information about the SDOH through HealthConnect. True
or False

50
12. If I think someone needs help with transportation but we don’t have any
resources for transportation I should skip those SDOH questions. True or
False
Thanks so much for taking this survey. You will re-take this survey after the SDOH
training, and we will measure the effectiveness of the education for social workers
around the SDOH measures.
Sincerely,
Ruth A. Vosmek, LCSW, DSW and the KP SDOH Design Team

51
Appendix I: Capstone High Fidelity Prototype: Implementation Manual
Link to PDF file below
05.27.2024 Print
Version SDOH Implementation Manual.pdf

52

SDOH Implementation Manual
Road to Equity
For Social Workers and Social Work Managers
Image by Diego Jimenez Unsplash.com

2
SDOH Implementation Manual
Road to Equity
For Social Workers and Social Work Managers
“Significant and persistent disparities in healthcare outcomes exist in the U.S. Belonging
to a racial or ethnic minority group, living with a disability, being a member of the lesbian,
gay, bisexual, transgender, and queer (LGBTQ+) community, being a member of a religious
minority, living in a rural area, or being near or below the poverty level, is often associated
with worse health outcomes.” -CMS

3
Preface
This project resulted from a mandate by CMS in 2020 to systematically screen for,
and attempt to meet the needs of, our patients in a domain known as the Social
Determinants of Health (SDOH). Social Workers have a long history of providing
resources and referrals, and counseling and advocacy, around these issues. This
project hopes to assist social work managers and others by creating a human centered approach to organizational change in order to enhance the ability of the team
to do accurate and efficient screening, assessment, and referrals for patients with
social health needs.

4
SDOH Implementation Manual
Table of Contents
For Social Workers and Social Work Managers
I. Introduction
a. Why is this important?
b. Alignment with SW Theory including Maslow’s Hierarchy of Needs
c. Alignment with Social Work Values and Ethics
II. Organizational Change Theory and Process
III. KP Process Implementation
a. The What: Which SDOH’s are we using?
b. The How
c. Updates to the new process
IV. Types of Barriers and Challenges for Social Workers
a. Why is this change important?
b. Comfort asking difficult questions
c. Rejection: what to do when clients don’t want to participate?
d. Fear of not having necessary resources to meet their clients’ needs
e. Fear of “dumbing down the profession” by using check boxes
V. Benefits of the New Model
a. Micro: Individual Level
b. Mezzo: Facility or Community Level
c. Macro: Larger Community Level and Legislative Advocacy
VI. Final Words
VII. Bibliography
VIII. Appendices
Appendix A Two Page Conversation Guide
Appendix B The AHC Health-Related Social Needs Screening Tool
Appendix C JOB AID/Video for Unite US Platform in HealthConnect
and What’s New How To information in HealthConnect
Appendix D User Journey Map
Appendix Z SDOH Resource Lists by facility (future state)

5
I. Introduction: The Why
According to the Joint Commission, The Social Determinants of Health (SDOH)
account for 80-90% of modifiable contributors to health outcomes. Because of
this, the Joint Commission along with Centers for Medicare and Medi-Cal services (CMS) are mandating that accredited hospitals and health systems identify
and address SDOH. Kaiser Northern California (NCAL) is designing new systems for identification of SDOH.
The first phase of this project focuses on getting accurate information into
HealthConnect. This involves training social work staff to the tools and platform
in EPIC (Electronic Health Record platform). During this phase, we will identify
barriers to the accurate completion of the screening tools, and work with social
workers to overcome these barriers.
This project focuses on the training needs of social workers assessing patients in
a medical setting across Northern California. It will help to identify barriers to the
goals associated with the SDOH project and link employees and their managers
to the resources needed to overcome resistance and challenges. This will help
ensure that end-user’s (KP patients) SDOH’s are appropriately identified, and
social workers can then assist patients to locate services that correspond to their
patients’ needs.
This is the individual (micro) level or stage of the project. During this phase,
social workers will be taught to utilize community-based services and resources, including UniteUs (database of resources), to assist patients in getting their
identifiable social needs met. It will also help us to capture service gaps for future
stages of this project.
Future stages of the project will continue to Close the Health Gap by identifying
and developing facility-specific resources in collaboration with community partners to meet clients’ needs (the meso- level); and finally completing a gap analysis to identify which SDOH problems are the most prominent, or the grizzliest,
and which may need additional funding, policy development, or resources (macro
level).

6
a. Alignment with SW Theory including Maslow’s Hierarchy of Needs
Theoretical and/or Conceptual Framework
Maslow’s hierarchy of needs
One of the fundamental social principles regarding the SDOH is best described
by Maslow’s hierarchy of needs. The pictorial representation of the hierarchy
of needs (not in Maslow’s article), shows that to achieve the higher levels depicted on the chart, one must first meet one’s basic needs. The assumption is
that one would have more difficulty meeting the Tier II basics like Health without
first achieving many of the more basics needs described on the bottom tier. The
SDOH are items that would appear on the bottom tiers – things like food, shelter, safety, and transportation. Indeed, we understand that many of these basic
needs are directly related to a person’s health.
b. Alignment with Social Work Values and Ethics
Social Workers have long been involved in helping to change people’s lives by
connecting clients with resources. It is one of the fundamental tasks in social
work. Systems theory and the ability to leverage resources to serve our clients is
a framework that helps us to “understand and address the complex dynamics of
human behavior and social systems” (Bouchrika, 2024). Helping achieve equity
in healthcare by connecting people with needed services to improve their health
is in alignment with social workers’ values. Social Justice and Service are two
of the values codified in the NASW Code of Ethics (Workers, 2017). The identification of SDOH is in line with both of these values.

7
NASW Standards for Social Work Practice in Health Care Settings
“A hallmark of social work’s commitment to health and well-being is the
profession’s continued focus on the issue of health care inequality in the
United States. People living in poverty and communities of color continue to experience disproportionately higher rates of acute and chronic
illness, due to the unequal access to healthcare services, lack of health
insurance coverage, poverty, discrimination, and other social determinants of health. Social workers recognize that reducing health disparities can only be accomplished by addressing the biopsychosocial-spiritual needs of individuals and families, as well as the systematic issues
that contribute to poor health outcomes.” (Cox, et al, 2016)
In future phases of this project, we are addressing 3 of Bronfenbrenner’s ecological system of five socio-economic levels: micro-, meso-, and macro- system
levels (leaving out exo-system and chrono-system levels). On the micro-system level, we are helping to address the individual’s needs through identification,
needs assessment and facilitated resource coordination to address individuals’
needs. On the meso-system level, we can determine which particular resources
may be missing or needed in a facility (like KP San Rafael hospital) or area (e.g.,
Marin/Sonoma Counties). And finally, on the macro-system level, Kaiser can
use data to look at the discovered needs to provide advocacy, community collaboration, and identify opportunities for community benefit funds to be used to help
solve for the SDOHs that are perhaps easiest to achieve, or maybe SDOHs that
are needed by the majority of members or community even if not the easiest to
accomplish.

8
II. Organizational Change Theory and Process
Theory of Change: Kotter’s
A theory of organizational change applicable to this project is Kotter’s processfocused eight step model that applies to organizational change. In this model
Kotter says that the following elements are desirable to create change: 1) Create
urgency - in this situation, explaining the mandate and the patients’ needs; 2)
Build a coalition; 3) Create vision; 4) Communicate the vision; 5) Empower others; 6) Create quick wins; 7) Build on change; and finally, 8) Embed the change.
This model applies to the change involved in bringing SDOH into the healthcare
world. This Implementation Module focuses on steps 1-6 of Kotter’s model.
A second model to combine with the process model above, is the people-focused
model by Satir that indicates that the people involved in change, in this case social workers, go through several steps that affect performance over time. These
steps include 1) The late status quo and then the introduction of a foreign
element (in this case, SDOH screening); 2) Resistance (or in this case, challenges and barriers); followed by 3) Chaos – where transforming ideas can be
introduced; then 4) Integration; and finally, 5) the New Status Quo. This model
is closely aligned with what we experienced when the new SDOH screening and
assessment workflow was being introduced.
In an effort to increase adherence to the SDOH process, 40 training courses
were conducted by a senior social worker who used human-centered design to
identify and address barriers or challenges faced by social workers. The User’s
Journey Map in Appendix D depicts 4-5 challenges to screening along with the
emotional response that needs to be addressed and some possible solutions to
the challenges that social workers face. These challenges to implementation
are a normal part of organizational change. This Implementation Manual is
designed to guide future education with new social workers and help to
inform the Social Work Managers regarding the needs of their staff during
the implementation phase.

9
III. KP Process Implementation
adequate quality and quantity of
food at household level
3
CMS Required Social Determinants of Health
Interpersonal Safety
Screening for exposure to
intimate partner violence, child
abuse, and elder abuse
Utility Difficulty
Inconsistent availability of
electricity, water, oil, and gas
services is directly associated
with housing instability and
food insecurity
Transportation Needs
Limitations that impede transportation
to destinations required for all aspects
of daily living
Food Insecurity
Limited or uncertain access to
Housing Instability
Inability to pay rent or mortgage, frequent changes
in residence including temporary stays, living in
crowded conditions, and actual lack of sheltered
housing in which an individual does not have a
personal residence
Regional Training Slide for SDOH
a. The What: Which SDOH’s are we using?
CMS and The Joint Commission requires SDOH screening in the 5 domains as
depicted in the infographic above: Interpersonal Safety; Housing Stability;
Transportation Needs; Utility Difficulty; and Food Insecurity.
Two areas are familiar to social workers who have been receiving referrals to see
identified patients for a number of years. These two areas are: Patient Safety,
which includes IPV and other forms of abuse; and Housing Stability. Both of
these areas are screened by nursing upon admission.
There are three new areas: Transportation Needs; Food Insecurity; and Utility Difficulty. These three areas will be screened by the Patient Care Coordinators (PCCs) or OB Nurses upon admission. The actual questions from the PCC’s
Initial Assessment (IA) are listed on the slide in the next few pages.
Kaiser chose to use many of the evidence-based questions from a previously validated social health screening tool, the Accountable Health Communities
(AHC) Health-Related Social Needs Screening Tool (United States, 2017). The
full tool is included in Appendix B for the curious.

10
2 “Signicant and persistent disparities in healthcare outcomes exist in the U.S. Belonging to a racial or ethnic
minority group, living with a disability, being a member of the lesbian, gay, bisexual, transgender, and queer
(LGBTQ+) community, being a member of a religious minority, living in a rural area, or being near or below the
poverty level, is often associated with worse health outcomes.” -CMS
CMS
IPPS
SDOH
1
SDOH
2 Equity
Added new structural measure
to the IQR program focused on
health equity: SDOH 1 & 2
CMS Released
2023 IPPS Final Rule
August 2022
Screen for Social
Drivers of
Health Measure*
Proportion of 18 y/o+ patients
who screen positive for having
one or more of those needs,
submitted as 5 separate
percentages
Screen Positive Rate
for Social Drivers
of Health Measure*
These SDOH measures are the
rst patient -level measurement
of social drivers of health in the
Hospital IQR program
Equity is a CMS
and KP Strategic
Priority
Captures if KP facility is
screening our 18 y/o+ patients
for health -related social needs
*SDOH measures are voluntary 2023 and mandatory January 1, 2024*
PCCCMs perform
high - level
Screen in flowsheets
MSWs perform detailed
assessment for ALL 5
SDOH domains
in flowsheets
Regional Training Slide (Flow Chart) for SDOH
b. The How
The new process starts with an initial screening by the floor nurses and Patient Care Coordinators (PCCs). When needs are identified in any of the
5 SDOH domains it will prompt a yellow or blue bell to occur in the social
worker’s patient list. In the past, these have shown up as referrals in their
HealthConnect In Basket but will now appear in their HealthConnect lists. The
yellow bells are the three questions asked by the PCCs (Food, Tranportation
and Utilities) and the blue bells are referrals coming from the floor nurses
(Safety and Housing).

11
Adult Services
SDOH 1st Screen:
• PCCCMs
• IPV question
bedside nursing
Mother/Baby/L&D
SDOH 1st Screen:
• RNs (OB Patient Profile-KPHC Build Requested)
Positive SDOH Screens
sent to MSW patient list
MSWs perform in depth
SDOH screen for all 5
domains:
1.Food insecurity
2.Housing instability
3.Transportation needs
4.Utility difficulties
5.Interpersonal safety
Inpatient SDOH Process Map
CMS Required Screening for 5 SDOH Domains *Inclusion Criteria: All inpatient admissions for patients 18+ on date of admission*
Regional Training Slide for SDOH
Below are the three questions that will be asked of every hospitalized patient by the PCCs. If any of the three questions are answered in the affirmative, it will prompt a yellow bell to appear on the “SDOH Identified” Tab:
5
PCCCM IA SDOH Flowsheet:
**Positive screens are sent to MSW patient list.
The completed flowsheet rows above will auto
populate in the corresponding MSW flowsheets**
Regional Training Slide for SDOH

12
Social Workers Screen for and Assist with the SDOH
Each time ANY SDOH is identified by nursing or PCCs, the Social Workers ask
10 mandated questions – starred below. These can be found on the Care Coordination Navigator or the Flow Sheets for Social Work.
6
MSW SDOH Flowsheet:
PCCCM answer will auto populate
PCCCM answer will auto populate
7
MSW SDOH Flowsheet:
This section gives the nuts and bolts of how to complete the SDOH assessment using the tools created by the builders. Below you will find the current KP
Healthstream module that explains the documentation that needs to be complet-

13
ed for the SDOH assessment by social workers.
Course: NCAL Social Work KPHC Documentation
Description: This module provides education on social worker documentation in KPHC.
Estimated Time: 30m
Course URL: https://www.healthstream.com/hlc/common/course/quicklinks.aspx?oid=3cd0
a430-5c7f-e111-bd11-001517135213&quickLink=YT0xJnRzPTIwMjQtMDItMjNUMjA6MDc6MTQmY2lkPTM4MDdkODY0LWMwZDEtZWUxMS05OTg5LTAwNTA1NmE3NmQxYSZjdj0w
c. Updates to the new process
Understanding and assisting with SDOH is an iterative process. After Kotter’s
Integration phase there is the final phase - the New Status Quo. It’s important
not to rest here, but to continue to listen to users (social workers) and end users
(patients) to develop better ways to assist our patients and our staff in understanding the importance of systematic screening for social determinants, and the
connection to health equity. Most importantly, we will focus on ongoing improvements in order to help with our ultimate goal of meeting the social needs of our
patients (members and non-members) to create a healthier community.

14
IV. Social Work Barriers and Challenges
During the initial phase of this project, it is important to meet the social workers
where they are at - - by defining and assisting with challenges, barriers and resistance faced by our social workers. In the low fidelity model described in Appendix
D, we identified specific challenges in 5 categories: 1) Need to understand why
this change is occurring and why it is important; 2) the need to increase comfort
asking difficult questions in a short period of time; 3) handling rejection when
clients don’t want to participate; 4) fear of not having resources requested/not
being able to meet their clients’ needs; and a new one that cropped up recently:
5) fear of “dumbing down the profession” by creating formulated questions to ask
patients. This manual will attempt to address these concerns.
1. Need to understand the change: Why are we changing the way we work?
Though social workers have long been an important part of hospital-based services, not every patient with an SDOH need is identified, and social workers
typically do not see every patient. In the current KP regional model all patients
are seen by nursing and PCCs, so these two groups of workers will do the initial
screening of all patients regarding the SDOH. The second level of screening,
which is much more in-depth, will be completed by KP social workers. The goal is
to meet the health-related social needs (HRSN) of individual patients in an effort
to decrease disparities in care.
A key to understanding the importance of identifying the Social Determinants
of Health (SDOH) in the KP population lies in understanding current evidence-based practice in this area. Over the past few years, the social justice
approach to meeting patients’ needs has been tried by a number of larger healthcare systems, including Kaiser Permanente and New York Presbyterian. These
healthcare organizations have identified and solved a few of the social determinants that can affect a person’s health. Kaiser Permanente has looked at food insecurity and the benefit of providing healthy meals to those in need, and the New
York Presbyterian found that they could identify unmet social need in about 17%
of their population by doing systematic screening for social health needs (Kaiser,
2023; Peretz et al, 2023). Both systems have shown that health improvements
can occur when they take a systematic approach to the identification of patient’s
social health needs and work together with community-based organizations to
provide services to persons with unmet social needs.
2. Increasing comfort asking difficult questions
Some of the social workers in the trainings that were conducted initially expressed discomfort asking personal questions of the clients – especially questions that they felt were invasive. The objective of the trainer at this point is to
help ease the feelings of anxiety that the typically less experienced social worker
might be experiencing through validation and give them tools to increase their
comfort in asking these particular difficult questions. Trainers can role model this
by asking the SDOH questions during the training. Another method is shadowing
or observation. There are opportunities to watch videos, observe a fellow so-

15
cial worker who is more comfortable with this activity, and managers can create
opportunities for role plays to assist social workers in practicing the skill of asking
difficult questions. The KP National SDOH Team created a two-page handout
and other resources to assist social workers with these concerns as well. These
resources can be found in the WHAT’s NEW, HOW TO tab in HealthConnect.
Find the tab that says Social Determinants of Care and enjoy the resources. (see
Appendix A)
3. When clients don’t want to answer questions
Some of the social workers in the training expressed concern that their patients
/ clients might not wish to answer the SDOH questions. Just as it is important for
social workers to understand the WHY behind the questions, in a parallel way,
clients need to understand why we are asking the SDOH questions as well. It’s
important to introduce the topic of the SDOH needs’ assessment.
Some examples of how to introduce this topic are included below:
You could introduce yourself then mention why you are there asking questions –
something like “I understand that you told a nurse that you were interested
in more information about food (or one of the other SDOHs).”
Or you could say “We are screening patients for social issues that may affect your health. Would you mind if I asked you some personal questions
to screen for any needs that you might have?”
You can elicit their permission to ask some follow-up questions. “If it’s ok with
you, I’d like to ask some other questions about your social health to see if
there are any barriers to health that we might be able to address together.”
If a patient or client says “No, I’m not interested in doing this. I think it’s rubbish,”
or something to this effect, you should treat this like any other encounter where
a patient refuses to meet with you and document the client’s refusal, leaving the
door open in case they change their mind by providing contact information for
you or your department, or leaving a flyer for them to examine.
Undercovering your own resistance to this work.
We certainly want to know if we are projecting our own fear of
asking these questions – and creating an environment where
clients don’t feel like the questions are the legitimate work of
the social worker. As with all new things, the more you understand and appreciate why you are doing something, the easier it
will be to gain agreement from another person.
Dealing with patients’ reticence or concerns is not new to our profession. How
many times have we wondered if we introduced ourselves well, or if we properly asked permission to engage. Feelings of rejection (why don’t they want to

16
talk with me) are part of the nature of our business. Still, it is helpful for social
workers to process their feelings with their manager or another mentor. There
is important information in our feelings, and it is helpful to uncover and process
this information. Most of the time patients will agree to work with you if you are
comfortable with the topic. However, even experienced social workers will face
rejection from time to time.
4. Concern that we may not have the resources to meet our clients’ needs.
As with all of the other concerns, this is a legitimate concern. It is borne out of
empathy for our clients. One social worker asked during the training “if we know
that there are no resources for housing in (her community), why are we asking
if they need help with housing?” The social worker was angry and felt that she
was being set up for failure and bad rapport with patients by asking questions
when we know that we lack services. She was naturally upset by the “mandatory”
CMS regulation.
One benefit to the individual client is that we can put this issue on a client’s
PROBLEM LIST for the future, and should a resource become available at a future date, this client will already be identified as someone who might benefit from
this resource. Kaiser can then reach out to our members to assist them.
It’s important to remember that the more Kaiser and CMS know about the needs
of our population, the easier it will be to create programs and support legislation
that will support the needs of our clients (macro level intervention).
5. Fear of “dumbing down the profession.”
One very experienced social worker asked if we didn’t think that creating a survey with drop down choices and asking questions a certain way was making
social workers automatons – making it so that they don’t have to think.
As with any evidence-based practice, it is helpful to adhere to the questions and
the way that they are phrased as closely as possible when using validated tools.
As opposed to dumbing down the profession, it takes skill and acumen to pull
off asking survey questions of this nature in a sensitive and professional manner. There is plenty of opportunity for social workers to utilize their professional
judgment regarding how they approach the questions, how they document, and
for them to utilize their professional judgment while interacting with patients. An
example of where social workers have adapted to the use of validated questionnaires in the past is in the area of mental health. Mental Health screeners, including social workers, ask validated survey questions about depression and anxiety
- such as the Beck Depression Inventory (BDI) for example. This helps patients
to rate their mental state and validate that they are making progress in their
treatment. These tools are now used regularly by clinicians to guide treatment
decisions. This has added to the professionalism of this field of practice and has
helped professionals to treat individuals with depression (Jackson-Koku, 2016;
Beck, 1996; Dimidjian, et al, 2006).
Finally, even experienced social workers return to the basics – and look at the
questions in a psychosocial assessment to make sure that there were not areas
that we have become numb to or accustomed to forgetting. Having the humility

17
to know that we all have blinders and areas to improve is one of the ways we can
continue to grow in our profession.
Appendix A and Appendix C have more resources to help social workers with
their concerns and challenges regarding SDOH practices.

18
V. Benefits of the New Model
a. Micro Level: Individual patients
As described previously, the benefits to the individual end user (patients), is that
their needs will be assessed by trained social workers, who will strive to address
their clients’ social health needs through identification and community resource
coordination.
When needs are unmet due to the inadequacy of a particular community resource there is still benefit in having identified a particular patient’s need. Having
the client’s need / risk / vulnerability identified in their record means that at a
future date, if the resource becomes available, then the information can be given
to the client in short order.
Data collection will be an important part of the process going forward. Improvements in health can be measured by a number of means including “health outcomes (e.g., blood glucose levels, blood pressure), process measures (e.g.,
medication adherence), utilization and cost (e.g., hospital admissions, ED visits),
and in the reduction / resolution of unmet social needs.” (TJC, 2022, p.4).
Kaiser has added to a national database of community resources available to
patients. This platform, called UniteUs, will eventually be available to KP patients.
For now, it is available to KP staff – and will aid in the coordination of Community
Resources associated with the Social Determinants of Health as well as other
needs.
See Appendix C includes Job Aid /Video for use of Thrive Local / UniteUs
platform within HealthConnect

19
b. Mezzo Level (Facilities and surrounding communities)
At the facility level, understanding the unmet needs of the community is important. Social Work Managers and others can collaborate with community providers
to meet the unmet needs of the community. A prime example of this is taken
from a research study that Kaiser is doing which identified an area of unmet
needs (food for people with diabetes living in a “food desert” or otherwise unable
to attain healthy food due to age or infirmity). The term “food as medicine” was
coined as a result of the importance of food for people with diabetes. Healthy,
home-delivered meals can make a positive difference in the lives of people with
diabetes – especially those who find it difficult to obtain or prepare healthy foods.
Another potential example of this is lack of appropriate transportation. In Marin
County, they found that people over 75-80 years of age are less likely to take
mass transit due to mobility issues. The community decided to meet that need by
offering elderly Marin residents the opportunity for taxi vouchers if they meet the
age or disability requirement. This request can be made through Marin County
Transit Authority – where travel navigators help to tailer transportation resources
for seniors and people with disabilities (Marin Transit, 2024).
Once data is in the system, the Social Work Managers can monitor this information that will be useful to them in establishing which problems or needs are most
prevalent in their area and which community partners they will need to collaborate with to provide needed services. Additional data will include the percent
increase in referrals so that they can anticipate needed staffing levels, as well as
which social workers need additional help to be more adherent to this mandate
or model.
c. Macro Level (larger community)
Kaiser has an opportunity to partner with municipalities, governmental agencies,
and community service agencies to meet the larger needs of the community that
it serves. The data from the SDOH screening can be used to find those resources most needed by KP members and commit community benefit funds to agencies that can help to meet those needs. We can use the data obtained by screening to advocate for increases in funding by KP and our legislators in areas that
we can prove through data, to be helpful to our patients and communities.

20
VI. Final Words
This is an exciting era for patients with unmet needs, and an equally exciting era
for hospital-based social workers. The work that CMS and the Joint Commission
are mandating is in line with the fundamental principles of social work and helps
to create equity for those who have been historically underrepresented and underserved.
NASW calls for social workers to use their leadership to “play an active role in
clinical, health services, and quality improvement research” (Cox, et al, p.41).
Ongoing involvement of social workers in the SDOH process calls for leadership
among all levels of social workers to continue to improve this process for both
users (social workers) and end users (patients). Finding new ways to help our
patients with the SDOH is one way that we can show leadership and become
involved in the process of increasing equity for all of our members and patients
that we serve.
Kaiser Permanente
Our Mission: Kaiser Permanente exists to provide high-quality, affordable health
care services and to improve the health of our members and the communities we
serve.
Our Vision: We are trusted partners in total health, collaborating with people to help
them thrive and creating communities that are among the healthiest in the nation.

21
Bibliography
Artiga, S., Hinton, E. (2018). Beyond health care: The role of social determinants in promoting health and health equity. Kaiser Family Foundation. https://www.kff.org/racial-equity-and-health-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/
Aubrey, A. (November 28, 2022). Doctors normally prescribed medicine and now some are prescribing meals. Morning Edition, NPR.
Beck, A.T., Steer, R.A., & Brown, G.K. (1996). Manual for the Beck Depression Inventory-II. Psychological Corporation.
Bouchrika, I. (2024, February 8). What is systems theory – social work theories in 2024. What is
Systems Theory? – Social Work Theories in 2024 | Research.com
Cherry, K. (August 16, 2023). Theories: Developmental Psychology: A comprehensive guide to
the Bronfenbrenner Ecological Model. https://www.verywellmind.com/bronfenbrenner-ecological-model-7643403
Cox, L., Fritz, T., Little, V., Otis-Green, S., & Yamamoto, A. (2016). NASW Standards for Social
Work Practice in Health Care Settings. National Association of Social Workers. NASWCulturalStandards2003.Q4.11 (socialworkers.org)
Dimidjian, S., Dobson, K.S., Kohlenbert, R.J., Gallop, R., Karkley, D.K., Atkins, D.C., Hollon, S.D.,
Schmaling, K.B., Addis, M.E., McGlinchey, J.b., Gollan, J.K., Dunner, D.L. & Jacobson,
N.S. (2006). Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. Journal of Consulting and Clinical Psychology, 74 (4), 658-670).
Jackson,-Koku, G. (March 2016). Beck Depression Inventory. Occupational Medicine, 66(2),
174-175. https://doi.org/10.1093/occmed/kqv087
Kaiser (August 2, 2023). Social health resources are just a click or call away. Kaiser Permanente
internal document.

22
Liedtka, J. & Ogilvie, T. (2011). Designing for growth: a design thinking tool kit for managers.
Columbia University Press.
Marin Transit Travel Navigators (2024). Travel Navigators | Marin Transit
Maslow, Abraham H. (1943). “A theory of human motivation”. Psychological Review. 50 (4): 370–
396.
Miller, K. (March 31, 2022). An elaborative explanation of the Satir Change Model. Comprehensive explanation of the Satir Change Model (crowjack.com)
Ndugga, N. & Artiga, S. (2021). Disparities in Health and Health Care: 5 Key Questions and Answers. Kaiser Family Foundation. https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and-health-care-5-key-question-and-answers/
Orgera, K. & Artiga, S. (August 2018). Disparities in Health and Health Care: Five Questions and
Answers. Kaiser Family Foundation, San Franciso, CA. Disparities in health and health
care: five key questions and answers - Digital Collections - National Library of Medicine
(nih.gov)
Peretz, P., Shapiro, A., Santos, L., Ogaye, K., Deland, E., Steel, P., Meyer, D. & Iyasere, J.
(2023). Social determinants of health screening and management: Lessons at a large, urban academic health system. The Joint Commission Journal on Quality and Patient Safety,
49, 328-332.
Ramirez, B., Baker, E.A., Metzler, M. (2008). Promoting health equity: A resource to help communities address social determinants of health. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.
Silverman, J., Krieger, J., Kiefer, M., Hebert, P., Robinson, J., & Nelson, K. (2015). The relationship between food insecurity and depression, diabetes distress and medication adherence
among low-income patients with poorly controlled diabetes. Journal of General Internal
Medicine, 30(10), 1476-1480
Social Health Bulletin (January 2024). Internal document. Kaiser Permanente. C-SHIP internal
document.

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The Joint Commission (June 20, 2022). R3 Report | Requirement, Rationale, Reference. New
Requirements to Reduce Health Care Disparities (Issue 36). The Joint Commission.
United States, U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. (2017, September 05). Accountable Health Communities Model. The AHC
Health-Related Social Needs Screening Tool (cms.gov).
Workers, N.A.(2017). NASW Code of Ethics (Guide to the Everyday Professional Conduct
of Social Workers). Washington, DC: NASW.

24
Appendix A: Two page Conversation Guide
Conversation Guide: Talking to Members About Social Health
Good health includes more than great medical care. Having a safe
place to live, healthy food to eat, and other essential aspects of
personal life circumstances — also known as social health — are as
important to a person’s total health as their physical and mental health.
We want to make having conversations about social circumstances feel
comfortable and normal for both you and KP members.
This guide is intended to help you:
• Engage by starting conversations about social health.
• Acknowledge patients’ responses and learn more.
• Empathize and seek to understand patients’ perspectives.
• Collaborate by partnering with patients on next steps.
Engage
Start the conversation.
Use this step to start a conversation about
potential social health concerns.
Explain why you’re talking about social health:
• Social health is an important part of an
individual’s total health.
• KP may be able to provide support for some
social health concerns.
• Anything you share is confidential, just like
your health information.
Support autonomy by asking
permission and giving patients
the option to decline.
Acknowledge
Acknowledge patients’ responses.
Always thank patients for sharing their social
health concerns (or for completing the social
health screening questionnaire), then:
• Summarize what you heard them say (or
responses you saw in the questionnaire).
• Ask permission to discuss their social health
concerns and give them the option to decline.
• Seek to understand their
priorities by asking open-ended
questions.
If patients say they don’t
want support, let them
know support is available if
needed at a later time.
Collaborate
Partner with patients on
next steps.
Invite patients to let you
know their preferences for
follow-up.
• Summarize key points from the conversations.
• Build on patients’ perspectives to determine
whether referrals or resource connections are
appropriate.
• Use an “ask-offer-ask” approach to understand
patients’ desires for support. (See example on
next page.)
• Leave the door open for future conversations.
Empathize
Seek to understand
patients’ perspectives
and experiences.
• Ask open-ended questions to hear patients’
perspectives and insights.
• Demonstrate your interest and respect for their
experiences and ideas.
• Use reflective statements that paraphrase
patients’ statements, emotions, priorities, or
concerns.
• Gain clarification and invite further discussion.
See the following page for some examples of what you might say.

25
0
Examples of what to say
Engage
Start the conversation.
• Anything major going on in your life lately?
• We’re asking all patients these questions so we
can do a good job of providing care that fits
your life. Anything you share is confidential,
just like your health information.
• We may be able to help with aspects of your
life that affect your health — such as food,
transportation, and housing.
• Is it OK to talk more about these
concerns? It’s OK if now is not
the right time.
Acknowledge
Acknowledge patients’ responses.
• I’m hearing that sometimes it’s hard to _____.
Would it be OK if we talk more about that?
• Thanks for responding to the questionnaire.
I see you have some challenges with ________.
Would you be willing to tell me a little more
about what’s going on? It’s OK if you don’t want
to talk about it.
• Of the concerns you’ve shared, which is your
highest priority?
If no support is
desired:
Thanks for sharing
your concerns.
Support is available
if, at any point, you
want to reach out.
Collaborate
Partner with patients
on next steps.
Summarize key points
• This has really been
bothering you and you’d
like to get some support.
• You’re not sure if you want any additional
services, but you’d like to get the information
just in case.
Ask-offer-ask
• Ask: Would you like some information about
___ resources?
• Offer: I can provide you with a phone number
for the ____ service today.
• Ask: How does that sound to you?
Empathize
Seek to understand
patients’ perspectives
and experiences.
Ask open-ended questions
• How do you see these challenges affecting
your health?
• If you’re up for it, I’d like to hear a little more
about how this is affecting you and your family.
Use reflective statements
• It sounds like this has been very stressful for
you.
• That sounds like a tough situation.
• I’m hearing that solving the challenge with
_____ is your highest priority.
For more information about resources available to members, go to kp.org/socialhealth.
v6_11/21/22

26
Appendix B
The AHC Health-Related Social Needs Screening Tool (cms.gov)
(government document included below – link to live document above)

27

28

29

30

31

32

33

34

35

36
Appendix C
Link below is an evening education session where UniteUs platform is discussed and Internet Resource obtained for a patient (starts at 40 secs)
Additional Training Resources can be found in What’s New How To in HealthConnect
When you go to the KP National SDOH Project (see arrow above) you will find these three
resources and more as of 4/2024 (being continually updated with resources). Links will be
active on the Sharepoint Site.
NCAL Sharepoint Site
https://sp-cloud.kp.org/sites/SocialHealthPractice2/SitePages/Training.
aspx?CT=1706570352982&OR=OWA-NT&CID=cbb62a29-9ef5-6e9c-e4eb-8b49f9936993

37

38
Appendix D
Social Work “User” Journey Map for SDOH Project

39
Appendix Z
(add here in future)
Community Resources for Each Facility in each of the five SDOH Domains

Abstract (if available)

Abstract According to the Joint Commission (TJC), The Social Determinants of Health (SDOH) account for 80-90% of modifiable contributors to health outcomes. Because of this, TJC along with Centers for Medicare and Medi-Cal services (CMS) are mandating that accredited hospitals and health systems identify and address SDOH. Despite the mandate, there are barriers to assessing for and addressing SDOH. Kaiser Permanente Northern California (KP NCAL) is designing new systems for identification of SDOH. This capstone helped to hone the tools developed in EPIC (Electronic Health Record platform). Using human centered design, this capstone project involved over 35 Kaiser Permanente training presentations enabling the identification of barriers to full implementation of the mandate, including screening and utilization of tools and resources to help patients (micro level). Findings and strategies for addressing obstacles were then incorporated into an Implementation Manual for Social Work Managers. Specific challenges to screening including areas of resistance, barriers, and challenges to the goals associated with the SDOH project are discussed using Kotter’s organizational change and Satir’s individual change models, along with recommendations for overcoming these challenges with the goal of increasing Kaiser’s ability to get accurate data and meet the SDOH needs of patients more efficiently and effectively. Data collection activities and Bronfenbrenner’s ecological framework of associated organizational Mezzo- and Macro- level goals are also discussed. This SDOH helps to create equity and close the health gap, one of the Grand Challenges in the field of Social Work.

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Asset Metadata

Creator Vosmek, Ruth Ann (author)

Core Title Social Determinants of Health: working with social workers and social work managers to build capacity to screen and refer in the medical setting

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Degree Conferral Date 2024-08

Publication Date 08/07/2024

Defense Date 07/29/2024

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag healthcare change,medical social work,OAI-PMH Harvest,organizational change,SDoH,SDOH Implementation Manual,social determinants of health,social health needs,Social Work,Social workers

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