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
JAMA
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.
JAMA
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
JAMA
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:

• Health and Human Services Integration: Generating Sustained Health and Equity Improvements
  C. Fichtenberg, J. Delva, K. Minyard, & L.M. Gottlieb
• The Organizational Risks of Cross-Sector Partnerships: A Comparison of Health and Human Services Perspectives
  S. Petchel, S. Gelmon, & B. Goldberg
• Cash Benchmarking For Integrated Health Care And Human Services Interventions: Finding The Value Added
  S.A. Berkowitz, S.T. Edwards, & D. Polsky
• Linking Health and Social Services Through Area Agencies on Aging is Associated with Lower Health Care Use and Spending
  A.L. Brewster, T.L. Wilson, J. Frehn, D. Berish & S.R. Kunkel
• Project Nurture Integrates Care and Services to Improve Outcomes for Opioid-Dependent Mothers and their Children
  K. John McConnell, M.R. Kaufman, J.I. Grunditz, et al.
• Embedding Social Workers in Veterans Health Administration Primary Care Teams Reduces Emergency Department Visits
  P.Y. Cornell, C.W. Halladay, J. Ader, et al.
• Housing Intervention for Medically Complex Families Associated with Improved Family Health: Pilot Randomized Trial
  A. Bovell-Ammon, C. Mansilla, A. Poblacion, et al.
• The Development of Health and Housing Consortia in New York City
  A.L. Freeman, B. Mohan, H. Lustgarten, et al.
• Integrating Health and Human Services in California's Whole Person Care Medicaid 1115 Waiver Demonstration
  E. Chuang, N. Pourat, L.A. Haley, B. O'Masta, E. Albertson, & C. Lu
• Buying Health For North Carolinians: Addressing Nonmedical Drivers Of Health At Scale
  Z. Wortman, E.C. Tilson, & M.K. Cohen
• Integrating Data to Advance Research, Operations, and Client-Centered Services in California
  E. Putnam-Hornstein, M. Ghaly, & M. Wilkening
• Implementing Community Resource Referral Technology: Facilitators and Barriers Described by Early Adopters
  Y. Cartier, C. Fichtenberg, & L.M. Gottlieb
• Financing the Infrastructure of Accountable Communities For Health is Key to Long-Term Sustainability
  D.L. Hughes & C. Mann
• Assessing the Capacity of Local Social Services Agencies to Respond to Referrals from Health Care Providers
  M. Kreuter, R. Garg, T. Thompson, et al.
• Innovative Integrated Health and Social Care Programs in Eleven High-Income Countries
  O. Bhattacharyya, J. Shaw, S. Sinha, et al.
• Innovative Policy Supports for Integrated Health and Social Care Programs in High-Income Countries
  W.P. Wodchis, J. Shaw, S. Sinha, O. Bhattacharyya, S. Shahid, & G. Anderson