Evidence & Resource Library

The SIREN Evidence & Resource Library has expanded to include both peer-reviewed publications and other types of resources such as webinars and screening tools/toolkits on medical and social care integration. To limit your search to peer-reviewed articles, select Peer Reviewed Research under Resource Type. If you have questions about how to use the library or suggestions about additional resources, write us at siren@ucsf.edu. Sign up to receive our monthly newsletter to get alerts about recent additions to the Evidence & Resource Library.

Displaying 1 - 10 of 30

Effects of a transitional care practice for a vulnerable population: A pragmatic, randomized comparative effectiveness trial

D.T. Liss, R.T. Ackermann, A. Cooper, E.A. Finch, C. Hurt, N. Lancki, A. Rogers, A. Sheth, C. Teter, C. Schaeffer
J Gen Intern Med

Background: There is limited experimental evidence on transitional care interventions beyond 30 days post-discharge and in vulnerable populations.

2019

Peer Reviewed Research

Randomized Controlled Trial (RCT)

A 60-second survey to identify patients’ unmet social needs

S.R. Reves, J.P. O’Neal, M.M. Gonzalez, C. McHenry, M. Favour, R.S. Etz
Ann Fam Med

The connection between poor social determinants of health and high utilization of health care is well established. The use of emergency departments for illnesses manageable within the community is common, as are hospitalizations due to preventable disease complications.

2019

Peer Reviewed Research

Other Study Design

Living alone and homelessness as predictors of 30-day potentially preventable hospital readmission

E. LaWall, Y.Y. Wu, V. Y. Fan, M. Ashton, T. Sentell
Prev Chronic Dis

Introduction: The effect of social factors on health care outcomes is widely recognized. Health care systems are encouraged to add social and behavioral measures to electronic health records (EHRs), but limited research demonstrates how to leverage this information.

2019

Peer Reviewed Research

Other Study Design

Incorporating social determinants of health in electronic health records: A qualitative study of perspectives on current practices among top vendors

M. Freij, P. Dullabh, L. Hovey, J. Leonard, A. Card, R. Dhopeshwarkar
U.S. Department of Health and Human Services Office of Health Policy

Background: Social determinants of health (SDH) are increasingly seen as important to understanding patient health and identifying appropriate interventions to improve health outcomes, in what is a complex interplay between health system, community, and individual level factors.

2018

Issue Briefs & Reports

Qualitative

Development of the pediatric social risk instrument using a structured panel approach

J. Cohen-Silver, S. Adams, R. Agrawal, C. Birken, E. Cohen, G. Dougherty, A. Houtrow, T. Jegathesan, S. Kandasamy, B. Muskat, N. Pai, J.L. Maguire
Clin Pediatr (Phila)

Background: Social determinants of health impact child illness. Currently, no instrument exists to identify social need during hospital admission.

2018

Peer Reviewed Research

Other Study Design

Medical respite for people experiencing homelessness: Financial impacts with alternative levels of Medicaid coverage

D. Shetler, D.S. Shepard
J Health Care Poor Underserved

Medical respite (MR) programs provide medical care, social services, and a safe place to recuperate for people experiencing homelessness after hospital discharge. We examined the financial impact of MR on hospitals and insurers in states with varying Medicaid coverage.

2018

Peer Reviewed Research

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 Evid Based Nurs

Background: Efforts to improve care transitions require coordination across the healthcare continuum and interventions that enhance communication between acute and community settings.

2018

Peer Reviewed Research

Pre-post with Comparison Group

Community navigators reduce hospital utilization in super-utilizers

M.P. Thompson, P.S.B. Podila, C. Clay, J. Sharp, S. Bailey-DeLeeuw, A.J. Berkley, B.G. Baker, T.M. Waters
Am J Manag Care

Objectives: Super-utilizers place a significant burden on the healthcare system. Blending the roles of patient navigators and community health workers may address the clinical and social needs of these patients.

2018

Peer Reviewed Research

Pre-post with Comparison Group

Hospital readmission and social risk factors identified from physician notes

A.S. Navathe, F. Zhong, V.J. Lei, F.Y. Chang, M. Sordo, M. Topaz, S.B. Navathe, R.A. Rocha, L. Zhou
Health Serv Res

Objective: To evaluate the prevalence of seven social factors using physician notes as compared to claims and structured electronic health records (EHRs) data and the resulting association with 30-day readmissions.

2018

Peer Reviewed Research

Other Study Design

ICD social codes: An underutilized resource for tracking social needs

J.M. Torres, J. Lawlor, J.D. Colvin, M.R. Sills, J.L. Bettenhausen, A. Davidson, G.J. Cutler, M. Hall, L.M. Gottlieb
Med Care

Background: Social determinants of health (SDH) data collected in health care settings could have important applications for clinical decision-making, population health strategies, and the design of performance-based incentives and penalties.

2017

Peer Reviewed Research

Descriptive/Association
CSV