What They’re Watching: Matthew Richards, MD, Northwest Permanente Medical Group

Matthew Richards, MD, is a Director at Northwest Permanente Medical Group. He joins in this edition of “What They’re Watching” to discuss the social determinants of health and Kaiser Permanente’s Thrive Local initiative.


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“The work that I lead at Kaiser Permanente is a regional initiative and it’s around in-patient care of hospitalized patients. Trying to focus on not just making high-quality medical care, but also focusing on high-quality non-medical care which includes their social determinants of health. Some of the cornerstones are that every patient who is hospitalized is getting a questionnaire to screen for any social determinants of health. So, looking at housing insecurity, food insecurity, transportation concerns, caregiving, social isolation – all of those things that we know can leave somebody susceptible to have an issue.

From there, our teams in the hospital — in particular our care coordination teams and our social work teams — are then trained to make connections with the patient, providing them with a resource pamphlet or making referrals as they need to. But then the thing that is the most exciting part of that is going to be our Thrive Local initiative which is partnering with Unite Us — a national organization that essentially becomes a technology platform and provides community-based organizations that can connect our patients to those community organizations through a systematized referral.

And through that referral platform, what we’ll eventually get in its final state is if you identify those needs on a screening questionnaire or in your conversation with a patient, you then make a referral through this platform that Unite Us has that includes community-based organizations all around. Then when they send that referral, you can send it to one or you can send it to ten organizations and then one grabs it. And then when they grab it and make that connection for the member, the others drop off and we get bi-directional communication that said, “Hey we met your member, we closed that need that they have, and we’ve taken care of them.”

And then I think from a larger system perspective what that Thrive Local provides for us is it’ll provide data and analytics that include things like how many referrals are being placed for this need — whether it’s transportation or housing or otherwise. And, which organizations are fulfilling the most of those referrals to let us know which organizations are able to provide that capacity, and could we do something to help expand their capacity? Or, if we’re finding that we’re making a ton of referrals that the community right now doesn’t have a ton of support for, can we then grant some proposals to provide funding that can help expand those organizations as well, or get a new organization in that can fulfill that need? And then ultimately what we’re hoping to see is that people’s health improves. And when their health improves because you’re addressing both their medical and their non-medical, then they’re not going to have to be in the hospital as often and they’ll be able to spend more nights in their own home.”