Evaluation of a Closed-Loop Referral Platform for Addressing Patient’s Social Needs

CHERYL KELLY
Investigator, Kaiser Permanente Colorado

Kaiser Permanente (KP) is investing in a close-loop social needs referral platform called Thrive Local. Thrive Local links clinical care to social care through data integration with community-based partner organizations. Thrive Local consists of three key functions: a resource directory that provides up-to-date and searchable information on community resources; geographically-based networks of social service organizations (i.e., Community Network); and a technology platform that engages clinicians and staff, members, and employees of community organizations to make rapid, secure referrals between health care providers and social care providers and track the outcomes of those referrals. The purpose of this poster is to describe the methods and approach being used to evaluate this initiative designed for real-world impact.

There are several study populations included in the evaluation. KP providers and staff who are trained to deliver the intervention and must modify existing workflows to integrate screening and referral of basic needs. Community-based organizations (CBOs) that are part of the community partner network in each region and are likely to experience an increase in referred clients seeking services. KP members who are screened for basic social needs and referred for services.

An evaluation of Thrive Local across eight KP regions is being led by Dr. Allen Cheadle from the Center for Community Health and Evaluation and Dr. Cheryl Kelly from the Partners in Evaluation & Research Center using the RE-AIM framework. The implementation evaluation methods include interviews with KP providers, CBOs, and patients as well review of secondary sources (e.g., progress reports and other documents generated). Reach is being measured by data generated by the referral platform on the number and type of referrals and their resolution. Effectiveness is being measured by a patient-reported outcomes and secondary use of electronic health records. The patient survey will assess whether social needs are being met and whether patients they are able to address needs that may arise in the future. Additionally, data on referrals and progress towards closing social needs will be matched to patient medical record number to assess longer-term changes in health outcomes and healthcare utilization.

This study is beginning implementation despite several challenges, including variability of implementation across regions, a diverse set of stakeholders, and a staggered roll-out of a common tool to screen for social needs. This poster presentation will share the evaluation methods and measures and details about how we are incorporating patient-reported outcomes and objective measures of health and healthcare utilization to evaluate the impact of a closed-loop referral platform to address patient’s social needs.