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Happy July! As usual, the SIREN Newsletter includes recently published research studies and other reports related to the integration of social and medical care. This month, we also highlight news from the June AcademyHealth Annual Research Meeting and July NACCHO Annual Meeting, a selection of “Social Prescribing In-The-News” items, and upcoming conferences and events that are likely to be of interest. As always, if there are any resources or events that you know about that aren’t on the website, do let us know.
Happy reading,
The SIREN Team

Social Prescribing Highlights from the AcademyHealth Annual Research Meeting & NACCHO Annual 2017

Academy Health Annual Research Meeting

It was great to see some of you at the AcademyHealth ARM in New Orleans last month. There was an impressive range of SIREN-related work presented, including entire sessions on how alternative payment models are being used to support more upstream activities. 

A few highlights: 
  • Seth Berkowitz, MD of Massachusetts General Hospital presented work projecting cost savings from SNAP enrollment, helping to build an economic case for health systems around linking patients to food benefits programs. 
  • Krisda Chaiyachati, MD, MPH, a RWJF Clinical Scholar at University of Pennsylvania, presented an intervention on post-discharge transportation and how hospitals are using of community benefit dollars. 
  • Joshua Vest, PhD, MPH from Indiana University presented his work examining how SDH data are recorded in EHRs using both structured and unstructured data. 
  • Robin Yabroff, PhD from the Office of the Assistant Secretary for Planning and Evaluation at the US Department of Health and Human Services facilitated a panel on expanding measures of social risk to inform evaluations of Medicare quality and payment policies.

National Association of County and City Health Officials (NACCHO) Annual Meeting 2017
Bridging Clinical Medicine and Population Health – Pittsburgh, PA
The NACCHO meeting this year included several sessions about social needs interventions in clinical settings, including:
  • Houston’s Healthy Food Prescription Program has built a multi-sector partnership to address food insecurity. Learn more about their program here.  
  • Rhode Island Community Health Teams use Community Health Workers as community extenders. Read up on this model here.
  • Maryland's Proposed Comprehensive Primary Care Model would expand care management support and services, including social services, to ambulatory health care provider practices. Find out more about their model here.
Read our full summary of the NACCHO meeting here.


Technical Assistance Providers Announced for CMMI’s Accountable Health Communities Model
Mathematica Policy Research, along with their partners Ascend IST, the Center for Health Care Strategies, and HealthBegins, have been selected to provide technical assistance to the Accountable Health Communities Model sites. Read more.
Newly Proposed Rule for MACRA Recognizes Screening for Health-Harming Legal Needs as an Improvement Activity Under Medicare’s Merit-Based Incentive Payment System
Public comments are being accepted through August 21stRead the rule and make a comment.

Upcoming Events

WEBINAR: Hospital-Community Partnerships: Using Local & Institutional Policy to Address Root Causes of Food Insecurity
Moving Health Care Upstream & ChangeLab Solutions
July 25, 2017, 10am – 11am PDT
Register now.
WEBINAR: Advancing Interoperable Social Determinants of Health (SDH)
Office of the National Coordinator for Health Information Technology
July 26th, 2017 9am - 1pm PDT
Register now.

WEBINAR: Information Sharing in Medical-Legal Partnerships
National Center for Medical-Legal Partnership
August 17, 2017 11am - 12pm PDT
Register now.
The Root Cause Coalition Annual National Summit on the Social Determinants of Health
October 9-10, 2017
Louisville, KY
Register now.

Social Prescribing in the News

Check out these recent popular press pieces that highlight or reference social prescribing interventions.
Health Center Helps Siouxlanders Meet Basic Needs to Improve Medical Outcomes
Siouxland Community Health Center staff remains committed to their social prescribing work even after their three-year pilot project facilitated by the National Association of Community Health Centers comes to an end. Read more in the Sioux City Journal.
How Doctors Find Value in Knowing Your Socioeconomic Data
The author highlights the benefits of screening for and addressing patient social needs by a patient navigator and keeping the information in patients’ medical records. Read more on the KUOW Site.

July 2017 Research Round-Up

See below for publications recently added to the SIREN Evidence Library.
As always, if you are aware of resources you think should be added to the Evidence Library, please send them our way!
Student Hotspotting: Teaching the Interprofessional Care of Complex Patients
P. Bedoya, K. Neuhausen, A. Dow, E.M. Brooks, D. Mautner, R.S. Etz
Academic Medicine
Presented in this paper are reflections from the five-student Virginia Commonwealth University (VCU) hotspotting team participating in the Camden Coalition of Healthcare Providers and the Association of American Medical Colleges Interprofessional Student Hotspotting Learning Collaborative. VCU students indicated that the program was successful in teaching students how social determinants affect health and the benefits of interprofessional teamwork for addressing the unmet health and social needs of complex patients.

Screening for Social Determinants of Health in Michigan Health Centers
E. Byhoff, A.J. Cohen, M.C. Hamati, et al.
Journal of the American Board of Family Medicine
This authors of this study investigate and characterize how social determinants of health (SDH) screening is incorporated into routine clinical practice in health centers that serve disadvantaged patient populations. Broad empiric consensus on a core set of 13 SDH screening domains that align with nationally recommended screening guidelines was observed.
A Social Needs Assessment Tool for an Urban Latino Population
B.A. Careyva, R. Hamadani, T. Friel, C.A. Coyne
Journal of Community Health
The authors of this study present results of focus groups that explored priority social needs, images to depict social need categories, and acceptability of a computer-based program to identify these needs. Though unmet social needs were identified across all groups, 36-64 year olds and Spanish-speaking Hispanic patients were disproportionately impacted by unmet social needs. Most participants noted that a tablet computer was an acceptable venue to share social needs, though a tutorial may be needed for patients in the 65 and older group.
Replicating Effective Models of Complex Care Management for Older Adults
K. Coburn, C. Grinberg, S. Demuynck, M. Hawthorne
Health Affairs Blog
The authors of this commentary discuss challenges and opportunities to innovating and replicating effective models of care for older adults with complex health and social needs. Authors note that models of care that are readily scalable have limited effectiveness, and effective models of complex care management are difficult to scale. The authors highlight the need for robust evaluation in order to learn how to spread effective programs.
A Community Resource Map to Support Clinical-Community Linkages in a Randomized Controlled Trial of Childhood Obesity, Eastern Massachusetts, 2014-2016
L. Fiechtner, G.C. Puente, M. Sharifi, et al.
Preventing Chronic Disease
This study describes the development and validation of an online interactive community resources map to improve outcomes for children at high risk for obesity. Parents reported that they were very satisfied with the information they received. Parent resource knowledge, ability to access resources, and use of community resources increased over time, and did not differ by whether participants received the online map or a mailed paper list of community resources.
Patient Engagement at the Margins: Health Care Providers' Assessments of Engagement and the Structural Determinants of Health in the Safety-Net
M.D. Fleming, J.K. Shim, I.H. Yen, et al.
Social Science & Medicine
This ethnographic study found that health care providers serving high cost patients, who often face complex social and economic hardships, consider patient engagement assessments to be highly challenging and oftentimes inaccurate, because they understood low patient engagement to be the result of difficult socioeconomic conditions.  For marginalized patients, providers often looked for more subtle and intuitive signs of engagement.
Developing Electronic Health Record (EHR) Strategies Related to Health Center Patients' Social Determinants of Health
R. Gold, E. Cottrell, A. Bunce, et al.
The Journal of American Board of Family Medicine
Standardizing social determinants of health (SDH) data collection and presentation in electronic health records (EHRs) could lead to improved patient and population health outcomes in community health centers (CHCs) and other care settings. This authors of this article present an example of a process through which stakeholder input informed the development of a preliminary set of EHR-based SDH data collection, summary and referral tools for CHCs.
A Systematic Review of Interventions on Patients' Social and Economic Needs
L.M. Gottlieb, H. Wing, N.E. Adler
American Journal of Preventive Medicine
This systematic review is a comprehensive picture of the evaluation landscape of nonmedical social needs interventions integrated into U.S. health care delivery systems. To date, evaluations have focused primarily on process and social outcomes and are often limited by poor study quality. Higher-quality studies that include common health and health care utilization outcomes would advance effectiveness research in this rapidly expanding field.
In Focus: Creating Pathways and Partnerships to Address Patients’ Social Needs. Transforming Care: Reporting on Health System Improvement
M. Hostetter & S. Klein
The Commonwealth Fund
The authors of this e-newsletter introduction provide an overview of how new technologies and payment models can support efforts by health care providers and health care plans to assess patients’ nonmedical risks and work with nonprofit agencies, social services providers, and other community partners to help address them.
Leveraging Technology to Find Solutions to Patients’ Unmet Social Needs. Transforming Care: Reporting on Health System Improvement
S. Klein & M. Hostetter
The Commonwealth Fund
In this newsletter item Klein & Hostetter highlight the emergence of electronic community resource locators and referral systems designed to enable providers to connect patients to needed community resources and to track referrals to these resources. The authors describe two of the vendors in this space: One Degree and NowPow.

Effective Care for High-Needs Patients - Opportunities for Improving Outcomes, Value, and Health
P. Long, M. Abrams, A. Milstein, et. al.
National Academy of Medicine
This National Academy of Medicine Special Publication presents the results of three workshops on improving care for high-needs patients. As part of the attributes of promising care models, the report identifies the need to carry out a multidimensional patient assessment that includes social needs, to extend care to the community and the home.
The Highland Health Advocates: A Preliminary Evaluation of a Novel Programme Addressing the Social Needs of Emergency Department Patients
L.I. Losonczy, D. Hsieh, M. Wang, et al.
Emergency Medicine Journal
This study examines the patient acceptability and impact of an ED-based help desk and medical-legal partnership staffed by undergraduate volunteers. The majority of patients who accessed the help desk found it helpful and were more often linked to a resource (59% vs 37%) and a medical home (92% vs 76%) than patients who received usual care on days with no help desk. There was no difference found in ED utilization, primary need resolution, or self-reported health status during this preliminary, quasi-experimental study.
Community Health Workers Bring Cost Savings to Patient-Centered Medical Homes
M.L. Moffett, A. Kaufman, A. Bazemore
Journal of Community Health
This study estimates the cost impacts of the Patient Centered Medical Home (PCMH) and the Integrated Primary Care and Community Support (I-PaCS) model, which uses community health workers (CHWs) to both coordinate care and help address patients’ social determinants of health. The programs were found to be complementary, with the I-PaCS program enhancing the cost reduction capability of the PCMH.
Does the Supplemental Nutrition Assistance Program Affect Hospital Utilization Among Older Adults? The Case of Maryland
L.J. Samuel, S.L. Szanton, R. Cahill, et al.
Population Health Management
In an examination of dually enrolled Maryland residents, the authors of this study found that Supplemental Nutrition Assistance Program (SNAP) participation was associated with reduced hospitalization, but not emergency department use. Further, the authors estimate that enrolling the 47% of the 2012 population who were eligible nonparticipants in SNAP could have saved $19 million in hospital costs.
Adding Social Determinant Data Changes Children's Hospitals' Readmissions Performance
M.R. Sills, M. Hall, G.J. Cutler, et al.
Journal of Pediatrics
This study tests whether social determinants of health (SDH) risk adjustment changes hospital-level performance on the 30-day Pediatric All-Condition Readmission (PACR) measure.  Adjustment for SDH made small but significant improvements in fit and accuracy of discharge-level PACR models, with a larger effect at the hospital level, changing decile-rank for 17 of 47 hospitals.

Information Sharing in Medical-Legal Partnerships: Foundational Concepts and Resources
J.H. Thorpe, L. Cartwright-Smith, E. Gray, M. Monegon
National Center for Medical-Legal Partnership
This brief describes how health care practitioners and legal services providers can share patient information within the boundaries of information privacy laws.
ICD Social Codes: An Underutilized Resource for Tracking Social Needs
J.M. Torres, J. Lawlor, J.D. Colvin, et al.
Medical Care
ICD-9 V codes could be used to capture social determinants of health data in electronic health records. The authors of this study explored how ICD-9 SDH V codes were used in a national inpatient discharge database. The authors found that SDH V codes were used in less than 2% of discharges overall.  Use was highest for diagnostic categories related to mental health and alcohol/substance use.

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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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