April 2018 Research Round-Up

Below we highlight recent literature on screening for and/or addressing social needs in clinical settings. To receive the Research Round-Up in your email, sign up for our monthly newsletter.

Find these articles and many more in our searchable Evidence Library.

Frequency of Food Insecurity and Associated Health Outcomes in Pediatric Patients at a Federally Qualified Health Center
K. Bahadur, S. Pai, E. Thoby, & A. Petrova
Journal of Community Health
In this observational study at an FQHC in New Jersey, 16% of screened children were found to be living in food insecure households. Children living in such a household were more likely to have at least one recorded morbidity.

Does the Chronic Care Model Meet the Emerging Needs of People Living with Multimorbidity? A Systematic Review and Thematic Synthesis
K.R. Boehmer, A.M. Abu Dabrh, M.R. Gionfriddo, P. Erwin, & V.M. Montori
PLoS One
This systematic review of Chronic Care Model (CCM) implementation found that CCM implementation rarely offered resources to address patients’ non-medical needs, such as financial assistance or transportation, and that only one third of studies were targeted to low SES patients.

Providing No-Cost Transport to Patients in an Underserved Area: Impact on Access to Physical Therapy
A.M. Bove, S.T. Gough, & L.R.M. Hausmann
Physiotherapy Theory and Practice
In this pre-post study, availability of a free door-to-door van service for outpatient physical therapy appointments coincided with a 5 percent increase in clinic attendance.

Using Quality Improvement to Improve Internal and External Coordination and Referrals
K.L. Cain & R.P. Collins
Journal of Public Health Management and Practice
This article reports on the impact of a quality improvement project aimed to improve referrals to the New Orleans Health Department's direct services programs, such as Health Care for the Homeless and Special Supplemental Nutrition Program for Women, from local clinics and hospitals.

Integrating Data on Social Determinants of Health into Electronic Health Records
M.N. Cantor & L. Thorpe
Health Affairs
This commentary highlights key challenges to integrating data on social determinants of health into electronic health records and offers recommendations for overcoming them.

Promoting Self-Management, Health Literacy and Social Capital to Reduce Health Inequalities in Older Adults Living in Urban Disadvantaged Areas: Protocol of the Randomised Controlled Trial AEQUALIS
L. Coll-Planas, S. Blancafort, X. Rojano, M. Roque, & R. Monteserin
BMC Public Health
This is a protocol for a pragmatic multi-site RCT of a primary care-based intervention among older adults aiming to promote social engagement, self-management and health literacy to reduce health inequities.

Addressing Social Determinants to Improve Patient Care and Promote Health Equity: An American College of Physicians Position Paper
H. Daniel, S.S. Bornstein, & G.C. Kane
Annals of Internal Medicine
In this position paper, the American College of Physicians acknowledges the role of social determinants in health, examines the complexities associated with them, and offers recommendations on better integrating of social determinants into the health care system while highlighting the need to address systemic issues hindering health equity.

Are Acute Care Settings Amenable to Addressing Patient Social Needs: A Sub-Group Analysis
L. Gottlieb, D. Hessler, D. Long, et al.
American Journal of Emergency Medicine
In this sub-group analysis of an RCT, the authors found that in-person navigation to social services improved parent-reported child health status and decreased social needs among acute-care pediatric patients more than receiving a list of social service resources.

Partnerships Between New York City Health Care Institutions and Community-Based Organizations
K. Griffin, C. Nelson, L. Realmuto, & L. Weiss
Greater New York Hospital Association & The New York Academy of Medicine
Building on recent national and New York state health care reform initiatives focused on addressing the social determinants of health, this report illuminates factors for successful partnerships between health care organizations and community-based organizations.

Reducing Emergency Room Visits and In-Hospitalizations by Implementing Best Practice for Transitional Care Using Innovative Technology and Big Data
S. Hewner, S.S. Sullivan, & G. Yu
Worldviews on Evidence-Based Nursing
This study evaluated the impact of a care-coordination intervention that used technology to identify high-risk individuals who might benefit from rapid nurse outreach to assess social and behavioral determinants of health. In a pre-post evaluation with control sites, the authors found that the intervention was associated with lower inpatient and emergency visits, increased outpatient visits, improved patient experience of care and provider work life.

How Integrating Health Care With Other Services Offers Significant Potential Benefits
J.R. Lumpkin & B.C. Quinn
Health Affairs Blog
The authors of this blog highlight the benefits of balancing and integrating health care with outside agencies addressing patients’ social determinants of health.

Investing in Social Services as a Core Strategy for Healthcare Organizations: Developing the Business Case
E. van Beek, D. Eckel, & A. Taylor
KPMG Government Institute
Based on the information gathered from field research and input from industry experts, the authors of this report define a set of six key steps to guide payer and provider organizations in setting up actionable business cases for social services investments.

A Real-World Community Health Worker Care Coordination Model for High-Risk Children
M.A. Martin, K. Perry-Bell, M. Minier, A.E. Glassgow, & B.W. Van Voorhees
Health Promotion Practice
The authors describe the development and deployment of a community health worker-led care coordination program that included delivery of social services within a state-run health system and highlight the potential of the program to serve as a model for integrating community health workers into clinical and community systems.

Continuous Quality Improvement and Comprehensive Primary Health Care: A Systems Framework to Improve Service Quality and Health Outcomes
J. McCalman, R. Bailie, R. Bainbridge, et al.
Frontiers in Public Health
This commentary highlights the ways continuous quality improvement methods can be used to improve health care-community linkages and advocacy to address social determinants of health.

The Clinical Examination and Socially At-Risk Populations: The Examination Matters for Health Disparities
K.A. Murphy, A. Ellison-Barnes, E.N. Johnson, & L.A. Cooper
Medical Clinics of North America
The authors of this article describe strategies for fostering relationship-centered care within routine clinical encounters to better uncover and address the social determinants of health that contribute to health disparities.

Provider Perspectives on the Collection of Social Determinants of Health
A. Palacio, D. Seo, H. Medina, V. Singh, M. Suarez, & L. Tamariz
Population Health Management
This cross-sectional survey of 240 clinical faculty of a large diverse medical school found that 82% of providers agreed that social determinants of health (SDH) are important predictors of health outcomes and quality of care and 58% believed the benefit of SDH collection outweighs the burden and associated risks. Racial ethnic minority status was associated with believing the benefit outweighs the burden.

Expenditure Reductions Associated with a Social Service Referral Program
Z. Pruitt, N. Emechebe, T. Quast, P. Taylor, & K. Bryant
Population Health Management
Use of a call center-based social service referral program designed to assist members of a Medicaid managed care organization with social needs was associated with reduced health care expenditures in the 12 months following the first social service referral.

Intimate Partner Violence Educational Materials in the Acute Care Setting: Acceptability and Impact on Female Caregiver Attitudes Toward Screening
K.A. Randell, A. Sherman, I. Walsh, D. O'Malley, & M.D. Dowd
Pediatric Emergency Care
This study found that intimate partner violence (IPV) materials displayed in pediatric emergency department or urgent care center restrooms were acceptable to most caregivers and that displaying materials did not negatively impact caregiver attitudes toward IPV screening.

Addressing Social Determinants of Health: Case Studies from Epic's Population Health Steering Board
P. Roberts, C. Deculus, L. Garber, A. Iivanainen, T. Stentoft, & K. Winright
Population Health Management
This article presents case studies contributed by organizations participating in the Epic Population Health Steering Board to offer insights into how health care providers can navigate challenges to building an effective system for social determinant of health screening, intervention, and measurement.

Fostering Local Health Department and Health System Collaboration Through Case Conferences for At-Risk and Vulnerable Populations
J.R. Vest, V. Caine, L.E. Harris, D.P. Watson, N. Menachemi, & P. Halverson
American Journal of Public Health
This qualitative study finds that integrating public health nurses into case conference teams in primary care health centers resulted in frequent referrals to local health department services, greater awareness of public health capabilities, and potential policy interventions to address social determinants of health.

Innovative Population Health Model Associated with Reduced Emergency Department Use and Inpatient Hospitalizations
D. Wesson, H. Kitzman, K.H. Halloran, & K. Tecson
Health Affairs
This pre-post study examined the impact of a primary care clinic integrating wellness and prevention programs in a city recreational center that included community health workers to assist with social needs such as transportation or healthy food access. Clinic patients showed a reduction in Emergency Department and inpatient care use 12 months after initiation of services.

From Classroom to Community: the Impact of a Non-Clinical Clerkship on Fourth-Year Medical Students' Ability to Address Social Determinants of Health
A. Wennerstrom, J.W. Gibson, & N.K. Krane
Medical Science Educator
This article reports findings from a pre-post evaluation of a community health clerkship for fourth-year medical students. Students reported significant changes in attitudes and knowledge of community health principles and expressed intent to contextualize care based on social circumstances.