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February 2019 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.

Journal Articles

Evaluation of a Novel Financial Navigator Pilot to Address Patient Concerns About Medical Care Costs
M.P. Banegas, J.F. Dickerson, N.L. Friedman, et al.
Permanente Journal
This evaluation of a Financial Navigator pilot designed to address patients' medical care cost needs and concerns found higher satisfaction with care and cost concerns assistance in intervention compared to control participants.

Mechanisms Associated with Clinical Improvement in Interventions that Address Health-Related Social Needs: A Mixed-Methods Analysis
S.A. Berkowitz, A.C. Hulberg AC, Placzek H, et al.
Population Health Management
This mixed methods study of a health-care based social needs linkage intervention found declines in cost-related medication underuse and transportation barriers but not in food insecurity between baseline and follow-up. Those who seemed to respond to the intervention and those who did not differed in terms of acuity of need, resource availability/access, and perceived adequacy of the resource utilized.

Health Care Utilization Following a Homeless Medical Respite Pilot Program
D.J. Biederman, J. Gamble, S. Wilson, C. Douglas, & J. Feigal
Public Health Nursing
This pre-post evaluation of a medical respite program for patients experiencing homelessness found reduced hospital admissions, fewer inpatient days for those admitted, increased outpatient provider visits, decreased health care charges, and improved housing and income in the year following program participation.

Access to Resources in the Community through Navigation: Protocol for a Mixed-Methods Feasibility Study
S. Dahrouge, A. Gauthier, F. Chiocchio, et al.
JMIR Research Protocols
This paper presents a protocol for a single-arm, mixed-methods, pre-post feasibility study of a navigator program in primary care practice settings with vulnerable populations.

Study protocol: A Pragmatic, Stepped-Wedge Trial of Tailored Support for Implementing Social Determinants of Health Documentation/Action in Community Health Centers, with Realist Evaluation
R. Gold, A. Bunce, E. Cottrell, et al.
Implementation Science
This is a protocol for a 5-year, mixed-methods, stepped-wedge trial with realist evaluation, designed to test the impact of providing 30 community health centers with guidance on implementing EHR-based social determinants of health documentation.

Identification and Management of Domestic and Sexual Violence in Primary Care in the #metoo Era: An Update
K. Hegarty & L. Tarzia
Current Psychiatry Reports
This paper discusses recent evidence around the identification and response to domestic and sexual violence in primary care for perpetrators and victims, highlighting the lack of research on perpetrator interventions.

Screening for Social Determinants of Health at Well-Child Appointments: A Quality Improvement Project
K. Higginbotham, T. Davis Crutcher, & S.M. Karp
Nursing Clinics of North America
This paper describes the implementation of a quality improvement project focused on food and housing insecurity screening and referrals during well-child appointments.

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
Preventing Chronic Disease
This study found that social isolation and homelessness data captured in EHRs at 2 urban hospitals in Hawaii did not predict 30-day potentially preventable readmissions after control for other factors such as physical frailty and medical complexity.

CommunityRx: A Real-World Controlled Clinical Trial of a Scalable, Low-Intensity Community Resource Referral Intervention
S.T. Lindau, J.A. Makelarski, E.M. Abramsohn, et al.
American Journal of Public Health
This study of a low-intensity, automated community resource referral intervention improved patient confidence in finding community resources to manage their health and almost half (48%) of individuals who recalled receiving referrals shared those resources with others. No impacts were observed on health-related quality of life.

Challenges and Successes with Food Resource Referrals for Food-Insecure Patients with Diabetes
S. Marpadga, A. Fernandez, J. Leung, A. Tang, H. Seligman, & E.J. Murphy
Permanente Journal
This study of a food resource referral program in a safety-net diabetes clinic found that, despite high prevalence of food insecurity (60%), provision of written and verbal information alone resulted in lower linkage rates (
Social Determinants of Health: Future Directions for Health Disparities Research
R.C. Palmer, D. Ismond, E.J. Rodriquez, & J.S. Kaufman
American Journal of Public Health
This editorial summarizes five key research directions for improving our understanding of how social determinants of health contribute to health disparities that emerged from a NIMHD science visioning process: (1) understanding the contributions of upstream social determinants of health, (2) embodiment, (3) protective factors and resiliency, (4) place and context, and (5) overcoming methodological challenges.

A Practical Approach to Assessing and Mitigating Loneliness and Isolation in Older Adults
C. Perissinotto, J. Holt-Lunstad, V.S. Periyakoil, & K. Covinsky
Journal of the American Geriatric Society
This conceptual paper provides a framework for health care systems, providers, and community members working with older adults to understand how loneliness affects health and how to ask about and document experiences of loneliness. The authors also give guidance on the future of interventions in this area.

Economic Benefit of "Modern" Nonemergency Medical Transportation that Utilizes Digital Transportation Networks
D.H. Rochlin, C.M. Lee, C. Scheuter, A. Milstein, & R.M. Kaplan
American Journal of Public Health
This cost-effectiveness analysis found that in comparison with traditional non-emergency medical transportation, NEMT that utilizes digital transportation networks might save $268 per expected user and $537 million annually when scaled nationally.

The Longitudinal Relationship Between Food Insecurity in Older Adults with Diabetes and Emergency Department Visits, Hospitalizations, Hemoglobin A1c, and Medication Adherence
E.B. Schroeder, C. Zeng, A.T. Sterrett, T.K. Kimpo, A.R. Paolino, & J.F. Steiner
Journal of Diabetes Complications
This study of older adults with diabetes found that individuals with food insecurity were more likely to have an ED visit or hospitalization and to have higher A1c in the year after the food security assessment, but there was no difference in medication adherence. Observed differences persisted with adjustment for basic demographic and clinical characteristics, but were attenuated with further adjustment for socioeconomic status, suggesting that adverse outcomes in diabetic individuals experiencing food insecurity may be driven by effects of food insecurity or be mediated by basic resource needs or lower socioeconomic status.

A Qualitative Study Examining Stakeholder Perspectives of a Local Child Abuse Program in Community Emergency Departments
G. Tiyyagura, P. Schaeffer, M. Gawel, J.M. Leventhal, M. Auerbach, & A.G. Asnes
Academic Pediatrics
This study of the implementation of a child abuse and neglect recognition and reporting intervention found that leadership support, engaged internal and external champions, and implementation flexibility all facilitated the program's implementation.

Medical-Legal Partnership: A Powerful Tool for Public Health and Health Justice
E. Tobin-Tyler & J.B. Teitelbaum
Public Health Reports
This commentary provides a brief overview of MLPs, discusses MLPs as a public health law intervention, and highlights opportunities for collaboration among MLPs, public health lawyers, and public health practitioners.


Using Health Homes to Integrate Care for Dually Eligible Individuals: Washington State’s Experiences
N. Archibald, K. Moses, L. Rava, & Center for Health Care Strategies
Integrated Care Resource Center
This report describes the structure and early implementation lessons from Washington State's demonstration under CMS' Financial Alignment Initiative, which aims to better integrate and coordinate care for dual eligibles.

Targeting High-Need Beneficiaries in Medicare Advantage: Opportunities to Address Medical and Social Needs
E.H. DuGoff, W. Buckingham, A.J.H. Kind, S. Chao, & G.F. Anderson
The Commonwealth Fund
Using data from the 2015 Medicare Health Outcomes Survey, the authors found that 37% of enrollees in large Medicare Advantage plans have high needs that require both medical and social services, suggesting that Medicare Advantage plans should be allowed to identify high-need beneficiaries based on both medical and social risk factors, rather than just medical diagnoses.

Identifying Social Risk and Needs in Health Care: Promising Approaches to Screening for Social Determinants of Health & Recommendations for Continued Exploration
National Alliance to Impact the Social Determinants of Health
This issue brief describes seven principles health care organizations should consider for patient screening, considers the benefits of secondary data for risk assessment versus screening, and recommends avenues for future research.

Opportunities for Complex Care Programs to Address the Social Determinants of Health
M. Schulman & C. Thomas-Henkel
Center for Health Care Strategies
This brief outlines opportunities to better address patients’ non-medical needs, identified from the Transforming Complex Care initiative: (1) identifying needs; (2) employing non-traditional workers; (3) partnering with community-based organizations and social service agencies; (4) testing new uses for technology to help address social needs; and (5) identifying sustainable funding to support non-medical services.