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July 2020 Newsletter

Like many of our stakeholders, the SIREN team continues to explore ways that the many forms of social adversity—and interventions to address adversity—are shaped by systems and structures founded in and perpetuated by racism. With the goal of improving our collective work, some of the things we’ve been reviewing include new proposed rigorous academic publishing standards on racial health inequities; associations between COVID-19-related health disparities and specific items in the PRAPARE social risk screening tool; and COVID-19's devastating force as a "Health Inequity Multiplier." And of course this newsletter is filled with our normal columns, too. Stay well, all—


New SIREN Supported Report & Webinar
Colleagues from Manatt Health released a report outlining circumstances in which health care organizations can exchange personal information outside the health care sector in compliance with federal and state law. The upcoming webinar on July 30, 2020 at 9am PT / 12pm ET will highlight four use cases that help to illustrate opportunities for the health care sector to share data with other organizations. Register here.
Gravity Project Updates

The Gravity Project continues its work to advance data standards related to social screening and social services-related interventions.  New ASPE Report
ASPE published its Second Report to Congress on Social Risk and Medicare’s Value-Based Purchasing Programs. The report explores emerging social risk awareness and assistance trends among providers, and highlights challenges including lack of standardization of social risk data collection and lack of evidence about intervention effectiveness, replicability, and scalability.

July Research Round-Up

This month yielded a bumper crop of articles, reports, and commentaries related to social interventions in health care. We highlight a sample of the crop below. For the complete list, click here.
Articles connecting COVID-19 and social risk screening/interventions

Structural Racism, Social Risk Factors, and Covid-19 — A Dangerous Convergence for Black Americans
L.E. Egede & R.J. Walker
The New England Journal of Medicine
This paper explores how structural racism shapes the distribution of both social determinants of health and more downstream social risk factors and goes on to recommend action items for mitigating structural racism.

Addressing Homelessness and Covid-19 Quarantine: A Streamlined Assessment and Referral Process
K. Hadden, D. Partlow, H. Liverett, N. Payakachat, et al.
NEJM Catalyst
This paper describes how one health system developed a screening tool and process to identify and refer patients unable to self-quarantine due to homelessness.
Medicaid Managed Care Plans Have an Opportunity to Play a Key Role in Recovery
J. Cantor, R. Tobey, & T. Kirui
Health Affairs Blog
In this blog post, the authors argue that Medicaid managed care plans can contribute to the nation’s wellbeing through investing in social interventions in community health centers, funding social service CBOs, hiring CHWs, and contributing to cross-sector coordinating entities.
Addressing Community Needs and Preparing for the Secondary Impacts of Covid-19
A. Quinn & M. Laws
NEJM Catalyst
This commentary argues that the health care sector must make long-term systems investments to stave off the catastrophic effects of the COVID-19 pandemic on the nation's social safety net.
Articles related to social risk screening
Developing Primary Care-Based Recommendations for Social Determinants of Health: Methods of the U.S. Preventive Services Task Force
K.W. Davidson, A.R. Kemper, C.A. Doubeni, C. Tseng, et al.
Annals of Internal Medicine
This article highlights social determinants already included in USPSTF recommendations and proposes a process by which others may be considered for primary care preventive recommendations.
Social Needs Screening and Referral Program at a Large US Public Hospital System, 2017
C. Berry, M. Paul, R. Massar, R.K. Marcello, & M. Krauskopf
American Journal of Public Health
The authors report on lessons learned from the implementation of an SDH screening and referral program at New York City Health + Hospitals, the largest public health care system in the United States.
Universal Screening of Social Determinants of Health at a Large US Academic Medical Center, 2018
D. Meyer, E. Lerner, A. Phillips, & K. Zumwalt
American Journal of Public Health
This article describes how NewYork-Presbyterian Hospital developed and implemented SDH screenings together with clinical screenings in four outpatient primary care sites.
Implementing a Social Determinants Screening and Referral Infrastructure During Routine Emergency Department Visits, Utah, 2017-2018
A.S. Wallace, B. Luther, J.W. Guo, C.Y. Wang, et al.
Preventing Chronic Disease
This article reports on a feasibility study that developed and evaluated an emergency department-based process to systematically identify social needs, facilitate access to community-based supportive services, and to integrate existing clinical and community-based referral data systems.
Articles on social services interventions
Addressing Financial Strain Through a Peer-to-Peer Intervention in Primary Care
A.D. Pinto, M. Da Ponte, M. Bondy, A. Craig-Neil, et al.
Family Practice
In this study, a primary care based peer-to-peer intervention helped address patients' financial strain, likely through reducing stigma, providing group support, and creating a space to discuss solutions.
Medical-Legal-Psychology Partnerships - Innovation in Addressing Social Determinants of Health in Pediatric Primary Care
R. Lawton, M. Whitehead, A. Henize, E. Fink, et al.
Academic Pediatrics
The authors describe the development of an integrated model that explicitly brings child psychologists into a medical-legal partnership to create a medical-legal-psychology partnership in a pediatric primary care setting.
Cost-effectiveness of Leveraging Social Determinants of Health to Improve Breast, Cervical, and Colorectal Cancer Screening: A Systematic Review
G. Mohan & S. Chattopadhyay
JAMA Oncology
This systematic review of economic evaluations indicates that increased SDH screening rates were associated with earlier cancer diagnosis and treatment and improved health outcomes with significant gains in QALYs.
Development of a Medically Tailored Hospital-Based Food Pantry System
F.M. Gany, S. Yorga, J. Ramirez, & L. Paolantonio
Journal of Health Care for the Poor and Underserved
The authors describe developing and implementing Food to Overcome Outcome Disparities (FOOD), an intervention that has established eleven medically tailored food pantries in New York City cancer centers.
Food is Medicine: Actions to Integrate Food and Nutrition into Healthcare
S. Downer, S.A. Berkowitz, T.S. Harlan, D.L. Olstad, & D. Mozaffarian
This paper reviews research on the “food is medicine” movement and reflects on food insecurity interventions in health care.
Demonstrated Health Care Cost Savings for Women: Findings from a Community Health Worker Intervention Designed to Address Depression and Unmet Social Needs
E.R. Embick, D.D. Maeng, I. Juskiewicz, C. Cerulli, et al.
Archives of Women’s Mental Health
A CHW intervention reduced health care costs for women with depression as compared to a non-CHW-based screening and referral program.
Effects of a Standardized Community Health Worker Intervention on Hospitalization Among Disadvantaged Patients with Multiple Chronic Conditions: A Pooled Analysis of Three Clinical Trials
A. Vasan, J.W. Morgan, N. Mitra, C. Xu, et al.
Health Services Research
The authors found that a standardized CHW intervention reduced total hospital days and hospitalizations outside the primary health system among a population of socioeconomically disadvantaged patients with multiple chronic conditions.
Articles on big social data and predictive modeling
Precision Health-Enabled Machine Learning to Identify Need for Wraparound Social Services Using Patient- and Population-Level Data Sets: Algorithm Development and Validation
S.N. Kasthurirathne, S. Grannis, P.K. Halverson, J. Morea, et al.
JMIR Medical Informatics
The authors of this article found that adding data about medication history, addiction and mental disorders, and patient-level social risk factors improved decision models predicting need for behavioral health, dietitian, social work, or other social service referrals, while additional population-level social determinants of health did not.
Artificial Intelligence and Medical Humanities
K. Ostherr
Journal of Medical Humanities
This article highlights four key areas of concern—data privacy and trust, flawed datasets and algorithmic bias, racial discrimination, and the rhetoric of humanism and disability—relating to the use of artificial intelligence in health and medicine, including in work related to social determinants of health.
Applying Big Data to Address the Social Determinants of Health in Oncology: Proceedings of a Workshop
National Academies of Sciences, Engineering, and Medicine
This report on a set of NASEM presentations and discussions explores the social determinants of health and their influence on cancer risk and outcomes; novel data sources and methodologies; data policy and ethical considerations regarding the use of big data; opportunities for collaboration and data sharing; and key research gaps.
Articles on the health care sector’s role in addressing social conditions
A Society of General Internal Medicine Position Statement on the Internists' Role in Social Determinants of Health
E. Byhoff, S. Kangovi, S.A. Berkowitz, M. DeCamp, et al.
Journal of General Internal Medicine
The position paper presents ways for internists to leverage their roles as practicing physicians, health system leaders, educators, researchers, and advocates to address individual social risks and upstream social determinants of health.
Ethics and Spheres of Influence in Addressing Social Determinants of Health
M. DeCamp, K. DeSalvo, & E. Dzeng
Journal of General Internal Medicine
This article applies the concept of “spheres of influence” to explore the ethical principles that should shape how clinicians, health care organizations, and the broader community address social determinants of health.

Read the complete list of this month's research publications here.

Upcoming Events

Each month, we highlight upcoming events that are likely to have substantial content related to the intersection of health and social care.

Center for Health Care Strategies webinar: How Community Health Workers and Promotores Can Support Individuals with Complex Needs Amid COVID-19 – July 29, 2020 | 10am PT / 1pm ET
Systems for Action webinar: Investigating Systems Alignment of Multi-Sector Agencies to Address Child Maltreatment in St. Louis – August 5, 2020 | 9am PT / 12pm ET
Healthcare Anchor Network: Aligning Your Anchor Mission for Post-Pandemic Impact: How Kaiser Permanente is Leveraging Its Assets to Rebuild Local Economies, Address Social Needs, and Advance Racial Equity – August 6, 2020 | 11am PT / 2pm ET
Manatt Health: State and Local Policy Learning Lab: How Health IT Can Support On-the-Ground Social Determinant of Health Initiatives – August 12, 2020 | 12:30pm PT / 3:30pm ET
AcademyHealth: 2020 Annual Research Meeting – July 28-August 6, 2020
Find a list of sessions that may be especially relevant to SIREN stakeholders here.

America’s Essential Hospitals: Vital 2020 – August 11-13, 2020 | August 18-20, 2020

Community Information Exchange Summit 2020 – August 12-14, 2020
This meeting features sessions co-developed by SIREN.

The Root Cause Coalition: Fifth National Summit on the Social Determinants of Health – October 5-7, 2020

In Case You Missed It

Aligning Systems for Health webinar: Theory of Change Charette – Originally broadcast June 24, 2020
NHCVA webinar: Telehealth Visits: Increasing Safety for People at Risk for Abuse – Originally broadcast June 25, 2020

Manatt Health webinar: SDOH and COVID-19: Opportunities, Barriers and Lessons We're Learning – Originally broadcast July 7, 2020

Funding Opportunity

2020 Systems for Action Supplemental COVID-19 Studies Call for Proposals (CFP)
The CFP will provide supplemental research funding to teams already engaged in the study of a promising system alignment mechanism, with the objective of learning how this mechanism performs in meeting both health and social needs during the COVID-19 pandemic. Funded studies will produce new scientific knowledge about the implementation and impact of existing, innovative strategies to align multiple financing and delivery systems supporting a Culture of Health. Studies must address one or more of the research priorities listed in the S4A Research Agenda and focus on one or more novel mechanisms for multi-sector alignment, integration, and improvement. Applications close Wednesday, August 5, 2020 at 12pm PT / 3pm ET.

In the Media

Below are recent non-academic articles about social interventions in health care. For lay media articles about the health equity impacts of COVID-19, see this list.
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The work of SIREN is made possible by the support of the Robert Wood Johnson Foundation, Kaiser Permanente, and the University of California, San Francisco.

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