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April 2020 Newsletter

Although all our lives have been upended by the coronavirus, it is increasingly clear that negative impacts are falling disproportionately on the most economically and socially disadvantaged, including people of color, low income families, undocumented immigrants, and incarcerated populations. In this context, evidence is more crucial than ever to help target resources to where they are most needed. We hope you find the information in this newsletter helpful as you continue your work.


SIREN COVID-19 resources
We’ve added to our list of pandemic-related resources. The page now includes: Integrating Social Services & Health
The April issue of Health Affairs is dedicated to the topic of health and social services integration. Seventeen articles examine challenges and opportunities of integrating services, including by addressing funding, technology, and workforce barriers. You can find these articles in the Research Round-Up. To highlight the issue, Health Affairs is hosting a series of online briefings; the next are on April 23rd and 30th. Register here.
Help improve interoperability of housing and transportation health related data in EHRs
The Gravity Project, an ONC-funded project advancing interoperability of SDH data in health care and beyond, is seeking submissions of data concepts on housing- and transportation-related screening and interventions in health care. Submit your concepts here

SIREN is hiring!
SIREN is seeking a talented and motivated postdoctoral fellow to work closely with our team for two years starting this summer. This is an ideal position for a recent doctoral degree graduate hoping to specialize in health care-based social interventions research. Click here for full position details.

April Research Round-Up

See below for a selection of publications recently added to the SIREN Evidence & Resource Library. As always, if you are aware of resources you think should be added to the Library please send them our way.
Social risk screening
Social Risks Among Primary Care Patients in a Large Urban Health System
C.G. Heller, A.S. Parsons, E.C. Chambers, K.P. Fiori, & C.D. Rehm
American Journal of Preventive Medicine
In a large sample of primary care patients in New York, 20% had at least one social risk. Low housing quality was the most commonly reported social risk for children and older adults while food insecurity was the most common social risk among middle-aged adults.
Addressing the Social Needs of Spanish- and English-Speaking Families in Pediatric Primary Care
S. Polk, K.M. Leifheit, R. Thornton, B.S. Solomon, & L.R. DeCamp
Academic Pediatrics
This social needs prevalence study carried out with families that received assistance from Health Leads in 2013-15 found that Spanish speakers most frequently reported needs related to food, whereas English speakers most frequently reported needs related to child care or child education.
Addressing Social Determinants of Health: Time for a Polysocial Risk Score
J.F. Figueroa, A.B. Frakt, & A.K. Jha
The authors of this viewpoint argue that developing an individualized “polysocial risk score” could help capture patient-level social risk without requiring the establishment of the precise contribution of each social factor.
Multi-risk assistance interventions
Medicaid and the Future of Health Care Hot-Spotting
J.C. Cantor
Milbank Memorial Fund
This brief highlights results of a New Jersey Medicaid ACO demonstration that used a hot-spotting approach for Medicaid and explores questions raised by recent research on hot-spotting approaches.
Where is the Break-even Point for Community Health Workers? Using National Data and Local Programmatic Costs to Find the Break-even Point for a Metropolitan Community Health Worker Program
T. Gurley-Calvez & J.A.R. Williams
Medical Care
This study estimated that 50 emergency department visits would need to be avoided per community health worker (assuming a caseload of 150 patients) to recoup program costs.
Homelessness interventions
Leveraging Legal Services on the Homeless Patient Aligned Care Team (H-PACT)
J. Trott & K. Lattimore
The National Center for Medical-Legal Partnership
This report profiles medical-legal partnerships that are successfully tackling the unmet legal needs of Veterans experiencing and at-risk of homelessness.
The Effectiveness of Case Management Interventions for the Homeless, Vulnerably Housed and Persons with Lived Experience: A Systematic Review
D. Ponka, E. Agbata, C. Kendall, et al.
PLoS One
This systematic review identified 56 studies examining the effectiveness and cost-effectiveness of case management interventions on health and social outcomes for homeless populations. Models of greater intensity improved outcomes, including housing stability.

Financial security interventions
Financial Support to Medicaid-Eligible Mothers Increases Caregiving for Preterm Infants
K.G. Andrews, M.W. Martin, E. Shenberger, S. Pereira, G. Fink, & M. McConnell
Maternal and Child Health Journal
In a small RCT at NICUs in Massachusetts, cash transfers to low-income mothers of hospitalized preterm infants increased daily visitation and the provision of skin-to-skin care and breastmilk.
Return on Investment from Co-locating Tax Assistance for Low-income Persons at Clinical Sites
S. Black, S. Sisco, T. Williams, et al.
An initiative that co-located tax return services at 4 clinical sites in New York City was estimated to generate a 673% return on investment based on the total federal refunds received by participants and the costs to the health systems and the partner organizations providing the tax assistance services.
Rationale for social interventions in health care settings
Health Care Organizations Can and Must Incorporate Social Determinants
H. Eisenson & N.S. Mohta
NEJM Catalyst Innovations in Care Delivery
This article summarizes results from a survey of health care executives, clinical leaders, and clinicians in January 2020 that identified improving clinical outcomes (91%) and improving patient experience/satisfaction (56%) as the top two benefits of collecting SDH data in primary care.
The Role of Physicians in Addressing Social Determinants of Health
N. Maani & S. Galea
In this viewpoint, the authors argue that physicians’ most important role related to social determinants of health lies in using their authoritative voice to highlight how social factors impact health and encouraging broader government and societal action to generate health.
Can Social Determinants of Health Programs Be Scaled? Interviews with Members of the NEJM Catalyst Insights Council on the Challenges of Scaling SDOH Programs
J. Bees
NEJM Catalyst Innovations in Care Delivery
The NEJM Catalyst Insights Council recognizes the link between social determinants of health and outcomes, but a lack of consensus on what to focus on first may hinder early success.
Integrating Social Services & Health
Health Affairs, April 2020 Special Issue
This special issue includes a number of articles on health and human services integration:

Upcoming Events

All In webinar: Leveraging Health and Housing Linkages in Response to COVID-19 
April 28, 2020 | 1pm PT/ 4pm ET
Patient Engagement HIT webinar: Data for Good: The Case for Operationalizing Social Determinants of Health into Clinical Models
April 29, 2020 | 10am PT/ 1pm ET
Systems for Action webinar: Integrating Cross-Sectoral Health and Social Services for the Homeless
April 29, 2020 | 9am PT/ 12pm ET
Systems for Action webinar: Testing an Integrated Delivery and Financing System for Older Adults with Health and Social Needs
May 13, 2020 | 9am PT/ 12pm ET

In Case You Missed It

National Center for Complex Health and Social Needs: Unique impacts of the COVID-19 pandemic on individuals with complex health and social needs - Originally broadcast April 3, 2020
Health Leads: Part 1: Equity’s Role in SDOH Interventions – Implementation - Originally broadcast April 7, 2020
The Social Determinants of Health Academy: Reducing Health Disparities Through Community Partnerships: Overview of the Issues - Originally broadcast April 8, 2020
Alliance for Health Policy: COVID-19 Webinar Series Session 9: Social Isolation and Loneliness - Originally broadcast April 14, 2020
John Hopkins Center for Health Equity: Care of Socially At-Risk Patient Populations during the COVID-19 Outbreak - Originally broadcast April 9, 2020
CHaSCI Community Webinar: Care Management in the Time of COVID-19 - Originally broadcast April 14, 2020
Systems for Action: Optimizing Governmental Health and Social Spending Interactions - Originally broadcast April 15, 2020

In the Media

For a more extensive list of recent articles on COVID-19 and health equity, click here.
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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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