The health and social impacts of the COVID-19 pandemic disproportionately affect individuals in historically underserved communities. This toolkit, developed by Kaiser Permanente, details a three-step process for provider organizations – specifically frontline staff and care team members in care coordination and care management roles – to support patients with unmet social needs in the current COVID-19 landscape. The process includes: (1) screening for unmet social needs (including for virtual settings); (2) connecting patients to community-based resources; (3) and following up on referrals. Additionally, there is substantial guidance on adapting these processes to support patients with behavioral health needs.

The toolkit includes appendices with implementation tools categorized by social need type and location (by-state resources are based in CA, CO, DC, GA, HI, MD, OR, VA, and WA.) Resources included in this toolkit are designed to support individuals experiencing housing instability, food insecurity, social isolation, and financial strain, with specialized resources focusing on seniors that also address topics such as family caregiver support and respite. While this toolkit was designed for providers to serve patients with COVID-19, many of these resources are broadly applicable for patients with unmet social needs.