February 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.

Research Articles

Using Applied Machine Learning to Predict Healthcare Utilization Based on Socioeconomic Determinants of Care
S. Chen, D. Bergman, K. Miller, A. Kavanagh, J. Frownfelter, & J. Showalter
American Journal of Managed Care
A machine learning approach based on SDH data was able to predict inpatient and emergency department utilization.

Utilising Clinical Settings to Identify and Respond to the Social Determinants of Health of Individuals with Type 2 Diabetes-A Review of the Literature
A. Frier, S. Devine, F. Barnett, & T. Dunning Health and Social Care in the Community
In the nine studies included in this review, written or telephonic social screening was most common. Income was the most commonly screened domain (9/9) and housing the least (1/9). Only one study described an approach to address social risks.

Creating Value for Communities: Los Angeles County's Investment in Housing for Health
R. Gupta, M. Ghaly, C. Todoroff, & S. Wali
Healthcare
This paper describes Los Angeles County's Housing for Health Program, which uses partnerships with housing facilities, a whole person approach with broad community-based resources, a local footprint in community health services, and a robust jail and prison transitions program to address the needs of high cost populations.

A Mixed-Methods Evaluation of a Novel Food Pantry in a Pediatric Primary Care Center
E. Hickey, M. Phan, A.F. Beck, M.C. Burkhardt, & M.D. Klein
Clinical Pediatrics
This pre-post controlled evaluation found no significant relationship between accessing a pediatric primary clinic-based food pantry and preventative service completion at 27 months of age; however, in interviews, pantry users expressed greater trust in the clinic.

Quantifying Health Systems' Investment in Social Determinants of Health, by Sector, 2017-19
L.I. Horwitz, C. Chang, H.N. Arcilla, & J.R. Knickman
Health Affairs
Researchers calculated that from 2017-2019, 57 US health systems invested over $2.5 billion in social determinants of health interventions, including $1.6 billion on housing.

Evidence-Based Community Health Worker Program Addresses Unmet Social Needs and Generates Positive Return on Investment
S. Kangovi, N. Mitra, D. Grande, J.A. Long, & D.A. Asch
Health Affairs
Economic analyses of a standardized CHW intervention (for which RCTs were published in 2014, 2017, and 2018) estimated that the intervention saves $2.47 for every dollar spent.

Upstream with a Small Paddle: How ACOs are Working Against the Current to Meet Patients' Social Needs
G.F. Murray, H.P. Rodriguez, & V.A. Lewis
Health Affairs
This qualitative study of 22 Accountable Care Organizations engaged in social needs activities found ACOs were challenged by lack of data on patients' social needs, difficulty building partnerships with CBOs, funding and financial regulations, and tension between short funding horizons and long-term impacts of social interventions.

Screening for Social Determinants of Health in Free and Charitable Clinics in North Carolina
D. Palakshappa, M. Scheerer, C.T. Semelka, & K.L. Foley
Journal of Health Care for the Poor and Underserved
In a survey of free and charitable clinics in North Carolina, 62% reported always screening for at least one SDH. Half of those who provided referrals reported following up with patients on resource use at next visit. Lack of personnel was the primary barrier to screening.

Impact of Transportation Interventions on Health Care Outcomes: A Systematic Review
E.M. Solomon, H. Wing, J.F. Steiner, & L.M. Gottlieb
Medical Care
This systematic review of health care sector-sponsored transportation intervention studies found only 8 studies. Studies found low patient uptake and inconsistent impacts on health and utilization outcomes.

Identification of Caregiver-Reported Social Risk Factors in Hospitalized Children
L.E. Vaz, D.V. Wagner, K.L. Ramsey, et al.
Hospital Pediatrics
A survey of caregivers at a children’s hospital in the Pacific Northwest found that 87% of caregivers were willing to be screened, and 1 in 3 reported financial stress (e.g., difficulty paying for food, rent, or utilities).

Reports & Commentaries

Commentaries about the Camden Coalition RCT published last month in the NEJM:

• Don’t Throw Cold Water On Health Care’s Hot Spotters, S. Kangovi & D. Grande, Health Affairs Blog
• “Super-Utilizer” Interventions: What They Reveal About Evaluation Research, Wishful Thinking, and Health Equity, P.M. Lantz, Milbank Q
• Beyond the Camden Coalition’s Randomized Controlled Trial: Lessons for the Complex Care Field on Addressing Patient Needs, L. Martin, The Better Care Playbook Blog
• Negative RCT of Health Care Hotspotting in NEJM: What Outcomes Are Important?, A. Pinto, The Upstream Lab
• Cold Water or Rocket Fuel? Lessons from the Camden “Hot-Spotting” Randomized Controlled Trial, E.C. Schneider & T.B. Shah, Health Affairs Blog

Z Codes Utilization among Medicare Fee-for-Service (FFS) Beneficiaries in 2017
Centers for Medicare & Medicaid Services Office of Minority Health
This CMS analysis of 2017 Medicare FFS claims data found that among 33.7 million beneficiaries, only 1.4% had claims with Z codes. Housing, social isolation, and interpersonal violence related codes were most common.

The Collaborative to Advance Social Health Integration: What We’re Learning About Delivering Whole-Person Care
Health Leads
This paper reports on key learnings from 21 primary care teams and community partners that worked together to improve their social needs programs. It includes recommendations and tools for improving practice, engaging patients, using patient-reported outcome measures, and making a business case for social interventions.

The Need to Incorporate Additional Patient Information into Risk Adjustment for Medicare Beneficiaries
K.J. Johnston, J.P.W. Bynum, & K.E. Joynt Maddox
JAMA
The authors of this viewpoint argue that the failure of the current risk adjustment system used by Medicare to include factors such as depression, dementia, frailty and social risk leads to inequitable performance measurement and reimbursement for clinicians, facilities, and health plans.

Social Needs Data in the State Medicaid Enrollment Form: A Content Analysis
R. Longyear, J.E. Moore JE, & C. Adams
Institute for Medicaid Innovation
This analysis of states' Medicaid enrollment forms found high variability in the number of social questions (ranging from 7 in MO to 21 in OR). 90% of states asked about language preference, 36% asked about housing or food assistance, 16% asked about family violence and 8% asked about transportation.