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Volume 4, Issue 3
The Impact of the Community Resource Specialist: Integrating a Lay Health Worker to Address Social Needs in Kaiser Permanente Washington clinics



What's going on?

The mounting prevalence of unmet social needs, such as lack of transportation, nutritious food, and financial strain has a direct effect on our members’ quality of life and health outcomes. Kaiser Permanente Washington Health Research Institute (KPWHRI) via its Learning Health System (LHS), partnered with KPWA’s delivery system to optimize the role of the Community Resource Specialist (CRS). The CRS seeks to ensure members’ social needs are addressed so they can meaningfully engage in their care plans.[1]

".... I would hope that most everyone knows about social determinants of health and the CRS role. I happen to have a public health background, so I'm more sensitive to it, maybe. So I can feel more confident saying "okay, I'll see you for follow-up so we can closely monitor this particular medical problem," knowing they're not going to have trouble finding transportation or being able to pay their co-pay to come in for their next appointment, so I can do my job more effectively and make more concrete plans for patients.”

~Clinician at Olympia Medical Center

In this report...

Over 18 months, the KPWHRI LHS research team partnered with KPWA’s Mental Health and Wellness department to (a) engage a subset of clinics in practice facilitation to identify best practices for standardizing CRS integration and services, (b) build Epic tools to ensure a population management based approach to patient care by the CRS team, and (c) conduct a rigorous evaluation of the CRS role. This report shares key learnings from our evaluation.

KPWA members responded to our survey at two time points, baseline and 3 months follow-up, indicating significant social needs (Table 1). Respondents included a comparison group of patients who had social needs but no CRS encounters, patients with a single CRS encounter, and patients who had 2 or more encounters with a CRS.

Table 1: Social needs table- responses to the survey question: Which of the following are the biggest problems for you right now?

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


  1. The CRS role is valued by care teams, reflects well on KP, and helps set KP apart in addressing social needs of our members

  2. Qualitative interviews with patients and care team members showed that the CRS helps them feel cared for and reflects well on the entire organization. Providing a human connection, building trust, and creating a stronger link to the care team were most often mentioned. Care teams reported that the CRS filled an important care gap and offered much needed services.

    “It's a very vital role. Everybody needs an advocate. I don't have an advocate. I have to constantly fight for everything. I have a notebook full of yes's and no's, steps and procedures, and I still don't get approval half the time. So, to have a CRS at Kaiser helping the people that need help, I think it's a fabulous idea.”

    ~Husband of a KPWA member

    Our survey also showed that 80% of members who interacted with the CRS “agree” or “strongly agree” that they feel supported by the CRS.

  3. Members who had 2 or more CRS encounters reported positive changes and were very satisfied with the CRS—members may need more than 1 encounter to benefit.
  4. Members who saw the CRS 2 or more times improved more on self-rated health than comparison patients who did not see the CRS. Compared to members with 1 encounter with CRS, those with 2+ encounters (Figure 1):

    • Reported higher self-efficacy to fulfill care plan
    • Reported more trust in their care team
    • Felt more like their care team is on task
    • Felt more of a bond with their care team
    • But did not demonstrate changes/improvements in social risk or coping despite our predictions otherwise

    Figure 1: Impact on KP members by CRS

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

  5. KPWA members have many unmet social needs that the CRS role can help address.
  6. 59% of members surveyed endorsed 1 or more social needs (food, housing, transportation, utilities, debt). Of those members, more than 90% said they would like help meeting those needs and nearly 25% endorsed having 3 or more social needs.

    “With housing, I worked with a woman who was a mother and had a young kid, like one year old. She was staying in the car and I gave her the resource to call for housing and she did, and she got housing within that week. So that was helpful. I could hear it in her voice, the follow-up call. She was like, ‘I got in, we're moving in.’”

    ~CRS

    Figure 2 lists the top referral categories by CRS

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

  7. Many members need significant support to overcome barriers to accessing resources—and to overcome the stigma associated with asking for help.
  8. CRSs were able to help people understand that it was OK to ask for assistance and to use the resources available—and they provided motivation and accountability to do so.


What's next:

  • Implementation of universal screening is critical for creating equitable access to the CRS service; one-third of respondents/participants (i.e., our comparison group) did not get access to the CRS individuals despite showing needs for their services. Implementation of social screening will ensure that all members with social needs could get help addressing their needs.
  • Provide additional training to CRSs in health and wellness support and the types of hands-on assistance members might need to create meaningful change in their social needs.
  • Continue supporting the CRS role and services, provide the physical space CRSs need to do their job well, and clarify the role of the CRS on the care team to improve role integration.