Department of Research & Evaluation News

Investigator Claudia Nau, PhD, of the Kaiser Permanente Southern California Department of Research & Evaluation, recently published a commentary on the role of predictive models in supporting a comprehensive national Kaiser Permanente social needs strategy.

How do social needs affect health?

Social needs include things such as whether people have time and money to buy and cook healthy meals, access to stores in neighborhoods that sell fruits and vegetables, or a safe neighborhood where people can walk. All these factors hugely influence our health. We’ve learned that often our ZIP code matters much more to our health than our genetic code.

Disparities in health and longevity among people of different races and socioeconomic classes are the most fundamental of all inequities. And they’re powerful. Up to 40% of health disparities can be attributed to these social needs. Kaiser Permanente is one of the first health care systems to not only seek to understand social needs related to health, but also to address these barriers to living a healthy life.

How can predictive modeling help Kaiser Permanente address social needs?

In this work, led by John Steiner, MD, MPH, the director of the Kaiser Permanente Social Needs Network for Evaluation and Translation (SONNET), we are using predictive modeling to help us systematically identify and help patients who don’t have access to healthy food or transportation to doctor appointments, to name just a few examples.

We use information from the electronic health record, such as missed appointments or prescriptions not picked up, to point us toward patients who might be struggling. Once we have identified these members, we can ask them if they have social needs.

What sparked your interest in this work?

I grew up in a family of factory workers and chimney sweeps in a small town in Germany. I was the first in my family to go to college and became fascinated with how the social contexts for fellow students shaped their mindsets, resources, and expectations. Learning about science, sociology, and demography in college allowed me to better understand people’s economic and social differences, and to find ways to address the inequities in health that can result from those differences.

Inequities in health are the most profound of all disparities because they are based on factors out of our control, such as who our parents are and where we were born. In college I worked to better understand what structural forces have repeated these patterns over centuries and across societies. Later, I moved to public health and eventually to Kaiser Permanente to help address these inequities.

How do social needs affect obesity and its related outcomes?

Obesity is affected by social needs because eating healthy foods and exercising require time, income, and local infrastructure such as gyms and grocery stores. For instance, people who are food insecure are more likely to be obese. Often the reason for that is they don’t have enough money to invest in healthy, low-calorie options, and are more likely to buy calorie-rich, filling foods.

When you aren’t working to improve the lives of people in Southern California, what do you do for fun?

I love to travel and to go hiking in the mountains and on the beach with my partner. I also enjoy running, yoga, reading, and teaching our hound-mix Toby silly tricks. I just went skydiving for the second time in my life, which is an experience that is almost as terrifying as it is amazing.

In the photo, I just summitted Mount Tallac at Lake Tahoe in the middle of the summer and found patches of snow still remaining.