Establishing a Regional Health System and Community-Based Organization Social Care Coordination Network: An Application of Geospatial Analysis

Abstract

Introduction: Adverse social determinants of health have been shown to be associated with a greater chance of developing chronic conditions. Although there has been increased focus on screening for health-related social needs (HRSNs) in health care delivery systems, it is seldom examined if the provision of needed services to address HRSNs is sufficiently available in communities where patients reside.

Methods: The authors used geospatial analysis to determine how well a newly formed health system and community-based organizations (CBOs) social care coordination network covered the areas in which a high number of patients experiencing HRSNs live. Geospatial clusters (hotspots) were constructed for Kaiser Permanente Northwest members experiencing any of the following 4 HRSNs: transportation needs, housing instability, food insecurity, or financial strain. Next, a geospatial polygon was calculated indicating whether a member could reach a social care provider within 30 minutes of travel time.

Results: A total of 185,535 Kaiser Permanente Northwest members completed a HRSN screener between April 2022 and April 2023. Overall, the authors found that among Kaiser Permanente Northwest members experiencing any of the 4 HRSNs, 97% to 98% of them were within 30 minutes of a social care provider. A small percentage of members who lived greater than 30 minutes to a social care provider were primarily located in rural areas.

Discussion and conclusion: This study demonstrates the importance of health system and community-based organization partnerships and investment in community resources to develop social care coordination networks, as well as how patient-level HRSN can be used to assess the coverage and representativeness of the network.

Keywords: community resource referral platform; geospatial analysis; health-related social needs; social determinants of health; social risks.

Figure 1:

Geomapping of member-level health-related social needs overlayed with social vulnerability index. Source: Esri, HERE, Garmin, © OpenStreetMap contributors, and the GIS user community. Used with permission.

Figure 2:

Geomapping of member-level health-related social needs overlayed with community resource referral network sites. Source: Esri, HERE, Garmin, © OpenStreetMap contributors, and the GIS user community. Used with permission.