Evaluation of the learning to integrate neighborhoods and clinical care project: Findings from implementing a new lay role into primary care teams to address social determinants of health

Introduction: Health systems increasingly recognize the impact of social determinants of health such as access to housing, transportation, and nutritious food. Lay health workers have been used to address patients’ social determinants of health through resource referral and goal setting in targeted populations, such as individuals with diabetes. However, we know of no studies that evaluate this type of role for a general primary care population.

Objective: To assess the implementation and impact of the Community Resource Specialist (CRS) role in Kaiser Permanente Washington. Methods: We analyzed data from staff interviews, patient focus groups, clinic site visits, patient surveys, the electronic health record, and administrative sources.

Results: Satisfaction with CRSs was high, with 92% of survey respondents choosing “very satisfied” or “somewhat satisfied.” Of patients with a resource referral and follow-up encounter, 45% reported using the resource (n = 229) and 86% who set a goal and had a follow-up encounter (n = 218) progressed toward their goal. Primary care teams reported workload easing. Patients who used CRSs and participated in focus groups reported behavior changes and improved health, although no changes were detected from electronic health records or patient survey data. Key learnings include the need to clearly define the CRS role, ensure high visibility to clinical staff, and facilitate personal introductions of patients (warm handoffs).

Conclusion: Adding an individual to the primary care team with expertise in community resources can increase patient satisfaction, support clinicians, and improve patients’ perceptions of their health and well-being.