Anand R. Shah, M.D., senior vice president of community and social health at Kaiser Permanente, was awarded a 2026 Alliance of Community Health Plans (ACHP) Bernard J. Tyson Health Equity Award, which was named after KP’s former CEO. Healthcare Innovation recently spoke with Shah about his team’s efforts to systematize and scale up social health efforts at the integrated health system that serves eight geographic areas across the country. 

Healthcare Innovation: Congratulations on winning the Alliance of Community Health Plans Award named for Bernard Tyson, former CEO at Kaiser Permanente. What did it mean to you to win an award named after Bernard Tyson, while you're working there at KP? 

Shah: It was a tremendous honor and and surprise. I did not know I was nominated. You always feel unworthy of such awards, even when you're proud. But I would say it meant a lot more for me in the sense that I had always admired Bernard Tyson, and it's part of what got me to connect with KP. The work in social health actually was created in many ways by Bernard Tyson's vision. He sponsored the initial role that brought me into KP, the vice president for social health, so as much as getting the award felt like a recognition, it also felt like a responsibility to carry the work forward.

HCI: Could you briefly talk about your background before coming to KP and how that work led to an interest in social health?

Shah: I’m an emergency physician by background. What brought me to emergency medicine was that early in life I had seen family members die prematurely abroad because of lack of access to care, and I had gotten the chance in in my college training to work in the NHS to see other systems of care. It made me think that we could organize care differently. And in medical school, emergency medicine was a place where you actually got to see systems work and not work on a daily basis and help people at some of their most vulnerable moments. But in addition to providing care, what was so meaningful for me was to think about how we could try to make these systems better. Ultimately, for almost everybody who show up in the ED, 99% of things are preventable. There are failures of the healthcare system, failures of our family systems, of our social safety nets, and others. That’s what inspired me and that's why I feel so lucky to work at an organization that's committed to thinking long-term about how to uplift not just individuals' lives, but also communities.

HCI: There was probably already a strong foundation at KP in the social health field when you arrived. Were there some initiatives that you wanted to put more emphasis on? Or new ones to launch? 

Shah: KP does have a long and proud tradition of being of the community and for the community. I would say many of our efforts were based on how we partner and invest in and support community organizations broadly, which was amazing. One of the opportunities was how to systematize our support for some of the most underserved and vulnerable members and patients that we see within our own systems. A lot of that work fell on the heroic actions of our physicians, nurses, managers, and social workers. We didn't really have a system to understand: Do they have needs? How do we support them? So we ended up doing a survey and found that about 60% of KP members have a social need. That was frankly a shock to many people because our members, by definition, are insured. One would have thought that they didn't have that level of vulnerability. So it created an impetus for us to build systems to better understand those needs, get them connected to services, and build a variety of programs.

HCI: Is there also a push to collect that social needs assessment at the point of care, and then have a way to have it represented in the electronic health record, so that when you come for a primary care visit, the clinicians know that about you?

Shah: Exactly. We started doing that in a systematic way for the first time five or six years ago. This year, I think we'll screen over 4 million members to get that information. We'll get it through mobile phones or at the point of care pre-visit, and it will be in the electronic health record. We also invested in the system so that they can get connected to services in the community, and we can understand if they got connected. We'll offer support to 1.5 million members. Not everyone we talk to needs assistance in that moment in time. But members knowing that we care and that we're trying to understand them as whole people is incredibly valuable, I think. I feel proud to be part of that.

HCI: You have a Community Support Hub. Is that a place where members can find a directory of community-based organizations?

Shah: It has that and other components. Members and non-members can go online and find support services. It also allows clinicians, care team members, and others to make referrals to an organization that would receive this information and would be able to document that you got services. It also has a call center where we receive calls, but more importantly, we do proactive outreach from that call center. We also do text messaging and leverage data analytics to identify folks who may be likely to have needs, so that we can do outreach or follow-up. It has a variety of different components that we bring together to complement what happens at the bedside. Because, like I said, a lot of this happens because we have really great clinical staff who do this oftentimes off the side of their desk. We’re trying to provide systems to make it easy and not reliant on that action.

HCI: I have interviewed KP’s Pamela Schwartz about the issue of medical respite care, and it seems the organization has been a pioneer in that area…

Shah: Respite care is helping individuals who are often unhoused and end up in our hospitals have a place to go. There's a variety of resources like respite care where the capacity in the community isn't available in all the communities where KP exists or beyond. So we've invested to increase the number of beds, but also to help create standards so that respite care providers have a consistent way to measure outcomes and partner with health systems. In addition to respite care, we're trying to uplift that capacity in other areas, so we've worked on medical legal partnerships to help avoid evictions, to increase support for food-as-medicine providers, to increase support for other services even outside of housing and food.

HCI: KP participates in Medi-Cal, California’s Medicaid program. Have there been some changes from the state’s Cal-AIM Medicaid transformation work that are allowing KP to partner to address member needs beyond their physical health in new ways?

Shah: Yes, we are very excited about how California has created a variety of what they call community support and enhanced case management. Essentially, they are reimbursing for care in the community or specific community services that should improve health outcomes. We've created three hubs across California that will work with hundreds or even thousands of community-based providers that we will refer to and pay them for the services that they provide in the community. We think it's a really important program. We also wrap around that other supports that aren't part of the Cal-AIM benefit. It is a model that's not unique to California. Oregon is trying aspects of this and North Carolina has done some work in this space.

HCI: Is part of your challenge looking at KP’s different regions across the country and deciding which things will work based on the local culture and regulatory or legal environment? Or do you put an emphasis on scaling up initiatives across the whole organization? 

Shah: It is a little bit of both. We try to bring the best to scale so that we can have common partners, platforms and best practices that we can bring into each community. But we we also have to tailor our offerings for each community. So it's maybe an 80/20 rule where we standardize what we can to make it more efficient and effective, but it will have to be tailored for that community’s needs. That's one of the biggest challenges and opportunities. The better you strike that balance, the better it works. Also, our population in America is aging, and the complexity of their needs is growing. Income inequality is continuing to grow and is driving health disparities. All that creates a dynamic environment that we have to continually adapt to. The local vs. standard adaptation is very much a part of that.

HCI: I have an upcoming interview scheduled with Esme Cullen, M.D., KP’s chief health equity officer for National Medicaid and State Programs, about the organization’s community health worker model. Is that an example of scaling up a program across multiple regions?

Shah: Very much so. We're very proud of that community health worker model. We see the community health workers as support in addition to the Community Support Hub because for many of our members telephonic support or digital support is important but probably not sufficient. Community health workers are natural helpers. They build trust and understand what's most important to a person, and then help them navigate those community-based and clinical services that help them stay healthy, so we're very excited about the impact it's had on people's well-being, and it's also saved dollars by reducing avoidable inpatient usage and emergency department usage.

HCI: Do you have a dashboard of metrics that you track to get a sense of how well you're doing at addressing some of these issues?

Shah: We keep a dashboard that reaches across a variety of domains. One is how many people are we providing support to, and I think I mentioned 1.5 million members that we've connected to services, and we also provide medical financial assistance. We also think about investments in the community and how they can be catalytic. We started a thriving communities fund that helped build affordable housing and we put $400 million in. It helped build 15,000 units, but it also catalyzed billions in additional investment. We also think about system-level changes. We've participated with City Health, which is a model that's helped provide healthy policies in 75 cities across the U.S., and we work with the Common Health Coalition of public health organizations. I think the metrics work to help us understand how we are supporting individuals and communities and how we are evolving systems and policies all at the same time.

HCI: Are there any other initiatives that you want to mention? 

Shah: One that we're proud of is the Population Health Management Initiative. We work with 32 federally qualified health centers across California and provide coaching, technical assistance, and technology to help them move toward value-based payment capabilities. Those FQHCs serve about 1.1 million members across California, and we've helped them improve clinical outcomes and their capabilities significantly in the last few years. The safety net is under a lot of pressure, so anything we can do to support safety net partners is incredibly important to KP because health is a common goal.