KP-published research on social needs and interventions

SONNET - October 2020

  1. Beck A, Davidson AJ, Xu S, Durfee MJ, Oronce CI, Steiner JF, Havranek EP. A multilevel analysis of individual, health system and neighborhood factors associated with depression within a large metropolitan area. J Urban Health 2017;94:780-790.

  2. Steiner JF, Zeng C. Universal vs. Risk-Based Screening for Food Insecurity. [letter ] Public Health Nutrition 2017;11:2076.

  3. Davidson AJ, Xu S, Oronce CI, Durfee MJ, McCormick EV, Steiner JF, Havranek EP, Beck A. Monitoring depression rates in an urban community: use of electronic health records. J Public Health Manag Pract 2018;24:e6-e14. doi: 10.1097/PHH.0000000000000751.

  4. Steiner JF, Stenmark SH, Sterrett AT, Paolino AR, Stiefel M, Gozansky WS, Zeng C. Food insecurity among older adults in an integrated health care system. J Am Geriatr Soc. 2018;66:1017-1024. doi:10.1111/jgs.15285.

  5. Steiner JF. Food insecurity – addressing basic resource needs in health care settings. Permanente J 2018;22:18-239. DOI: [Introduction to special supplement of Permanente Journal, Fall 2018]

  6. Hsu C, Hertel E, Johnson E, Cahill C, Lozano P, Ross TR, Ehrlich K, Coleman K, BlueSpruce J, Cheadle A, Matthys J, Chapdelaine M, Gray M, Tufte J, Robbins M. 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. Permanente J 2018;22:18-101. DOI:

  7. Hamity C, Jackson A, Peralta L, Bellows J. Perceptions and experience of patients, staff and clinicians with social needs assessment. Permanente J 2018;22:18-105. DOI:

  8. Gusoff G, Fichtenberg C, Gottlieb LM. Professional medical association policy statements on social health assessments and interventions. Perm J 2018;22:18-092. DOI:

  9. Gottlieb LM, Francis DE, Beck AF. Uses and misuses of patient- and neighborhood-level social determinants of health data. Perm J 2018;22:18-078. DOI:

  10. Schmittdiel JA, Dyer WT, Marshall CJ, Bivins R. Using neighborhood-level census data to predict diabetes progression in patients with laboratory-defined prediabetes. Permanente J 2018;22:18-096. DOI:

  11. Sundar KR. Universal screening for social needs in a primary care clinic: a quality improvement approach using the Your Current Life Situation survey. Permanente J 2018;22:18-089. DOI:

  12. Steiner JF, Kimpo TK, Lawton CI, Sterrett AT, Paolino AR, Zeng C. Measuring Basic Resource Needs: The Role of Small Surveys to Guide Operational Decisions. Permanente J 2018;22:18-098. DOI:

  13. Solomon L, Kanter MH. Health care steps up to social determinants of health: Current context. Perm J 2018;22:18-139. DOI:

  14. Steiner JF, Bellows J, Banegas MP, Gottlieb LM. Interventions to Address Basic Resource Needs in Kaiser Permanente: A care continuum and an outcomes wheel. Permanente J 2018;22:18-130. DOI:

  15. Friedman NL, Banegas MP. Toward addressing social determinants of health: a health care system strategy. Permanente J 2018;22:18-095. DOI:

  16. Stenmark SH, Steiner JF, Marpagda S, DeBor M, Underhill K, Seligman HK. Lessons learned from implementation of the food insecurity screening and referral program at Kaiser Permanente Colorado. Permanente J 2018;22:18-093. DOI:

  17. Banegas MP, Dickerson JF, Friedman NL, Mosen D, Ender AX, Chang TR, Runge EA, Hornbrook MC. Evaluation of a novel financial navigator pilot to address patient concerns about medical care costs. Permanente J 2019;23:18-084.

  18. Steiner JF. Assessing the unintended consequences of social interventions. Ann Fam Med 2019;17:[Invited commentary on Gottlieb LM, Alderwick H. Integrating social and medical care: could it worsen health and increase inequality? Ann Fam Med 2019;17: 77-81.]

  19. Schroeder EB, Zeng C, Sterrett AT, Kimpo TK, Paolino AR, Steiner JF. The longitudinal relationship between food insecurity in older adults with diabetes and emergency department visits, hospitalizations, hemoglobin A1c, and medication adherence. J Diabetes Complications 2019;33:289-295.

  20. Schickedanz A, Hamity C, Rogers A, Sharp AL, Jackson A. Clinician experiences and attitudes regarding screening for social determinants of health in a large integrated health care system. Med Care 2019;57:S197-S201.

  21. Henrikson NB, Banegas MP, Tuzzio L, Lim C, Schneider JL, Walsh-Bailey C, Scrol A, Hodge SM. Workflow requirements for cost-of-care conversations in outpatient settings providing oncology or primary care: a qualitative, human-centered design study. Ann Intern Med 2019:170:(9_Supplement:S70-S78. doi: 10.7326/M18-2227. PMID: 31060061.

  22. Nau C, Adams JL, Roblin D, Schmittdiel JA, Schroeder EB, Steiner JF. Considerations for identifying social needs in health care systems: A commentary on the role of predictive models in supporting a comprehensive social needs strategy. Med Care 2019;57:661-666.

  23. Schickedanz A, Sharp A, Hu YR, Shah NR, Adams JL, Francis D, Rogers A. Impact of social needs navigation on utilization among high utilizers in a large integrated health care system: a quasi-experimental study. J Gen Intern Med 2019;34:2382-2389.

  24. Mosen DM, Banegas MP, Benuzillo JG, Hu WR, Brooks NB, Ertz-Berger BL. Association between social and economic needs with future healthcare utilization. Am J Prev Med 2019:000(000):1-4.

  25. Mosen DM, Banegas MP, Friedman N, Shuster E, Brooks N. Food insecurity associated with self-reported falls among Medicare Advantage members. Popul Health Manag 2019:22:536-539.

  26. Shields-Zeeman, Laura, Cara Lewis, and Laura Gottlieb. "Social and Mental Health Care Integration: The Leading Edge." JAMA psychiatry 76.9 (2019): 881-882.

  27. Henrikson, Nora B., et al. "Psychometric and pragmatic properties of social risk screening tools: a systematic review." American journal of preventive medicine 57.6 (2019): S13-S24.

  28. Rogers AJ, Hamity C, Sharp AL, Jackson AH, Schickedanz AB. Patients’ attitudes and perceptions regarding social needs screening and navigation: Multi-site survey in a large integrated health system. J Gen Intern Med 2020: May;35(5):1389-1395. DOI: 10.1007/211606-019-05588-1.

  29. Solomon EM, Wing H, Steiner JF, Gottlieb LM. Impact of Transportation Interventions on Health Care Outcomes: A Systematic Review. Med Care. 2020;58(4):384-391. doi:10.1097/MLR.0000000000001292

  30. Rogers A, Hu YR, Schickedanz A, Gottlieb L, Sharp A. Understanding High-Utilizing Patients Based on Social Risk Profiles: a Latent Class Analysis Within an Integrated Health System. J Gen Intern Med. 2020;35(7):2214-2216. doi:10.1007/s11606-019-05510-9

  31. Lewis CC, Wellman R, Jones SM, Walsh-Bailey C, Thompson E, Derus A, Paolino AR, Steiner JF, De Marchis EH, Gottlieb LM, Sharp AL. Comparing the performance of two social risk screening tools in a vulnerable subpopulation. J Family Med Prim Care 2020;9:5026-34.

  32. Xu S, Goodrich GK, Moore KR, Manson SM, Gottlieb LM, Jessler D, Schroeder DB, Steiner JF. Identifying relative changes in social risk factors: an analytic approach. Med Care (in press).