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June 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

Addressing Health-Related Social Needs: Value-Based Care or Values-Based Care?
S.A. Berkowitz, T.P. Baggett, & S.T. Edwards
Journal of General Internal Medicine
This commentary identifies health- and market-based justifications for intervening on health-related social needs, cautions against over-reliance on market-based justifications, and presents key questions on how to evaluate these interventions.

Impact of a Community Health Worker Program to Support Caregivers of Children with Special Health Care Needs and Address Social Determinants of Health
M.A. Costich, P.J. Peretz, J.A. Davis, M.S. Stockwell, & L.A. Matiz
Clinical Pediatrics
A retrospective, pre-post analysis of a clinical health worker intervention found significant improvement in caregiver distress scores and lower caregiver report of food and housing issues.

Care Management for Older Adults: The Roles of Nurses, Social Workers, and Physicians
K. Donelan, Y. Chang, J. Berrett-Abebe, et al.
Health Affairs
A national survey of clinicians in practices caring for frail older adults found that social workers were more likely than RNs to participate in social needs assessments and that physicians’ involvement in social needs assessment and care coordination declined significantly when social workers, RNs, or both were employed in the practice.

Loss of SNAP is Associated with Food Insecurity and Poor Health in Working Families with Young Children
S. Ettinger de Cuba, M. Chilton, A. Bovell-Ammon, et al.
Health Affairs
This study of families with young children from 2007-2015 found that reduced SNAP benefits were associated with increased odds of household and child food insecurity and of fair or poor caregiver and child health.

Screening and Referral for Low-Income Families’ Social Determinants of Health by US Pediatricians
A. Garg, W. Cull, L. Olson, et al.
Academic Pediatrics
A national survey of pediatricians found that while most (62%) thought that screening for social determinants of health is important, fewer (20%) felt prepared to address families’ social needs. Those who endorsed the importance of screening and who reported being prepared were more likely to screen/refer.

Effects of a Transitional Care Practice for a Vulnerable Population: A Pragmatic, Randomized Comparative Effectiveness Trial
D.T. Liss, R.T. Ackermann, A. Cooper, et al.
Journal of General Internal Medicine
A patient-centered transitional care intervention that included assistance with social needs did not reduce 90-day mortality or hospital encounters but did decrease inpatient admissions over 180 days.

Medicaid Expansion in Social Context: Examining Relationships Between Medicaid Enrollment and County-Level Food Insecurity
S. Londhe, G. Ritter, & M. Schlesinger
Journal of Health Care for the Poor and Underserved
This study of Medicaid enrollment and food insecurity found that Medicaid expansion was associated with reduced food insecurity, the most pronounced associations evident in counties with the largest Medicaid expansions.

Caregivers’ Experiences with Food Insecurity Screening and Impact of Food Insecurity Resources
C.J. Orr, C. Chauvenet, H. Ozgun, C. Pamanes-Duran, & K.B. Flower
Clinical Pediatrics
In this qualitative study, food insecure caregivers of children described food insecurity screening as acceptable but reported not always being connected with resources. WIC was the most commonly used program to address food insecurity; caregivers infrequently utilized other food insecurity resources.

Trust Between Health Care and Community Organizations
S.S. Stout, L.A. Simpson, & P. Singh
This commentary describes three principles that are required for health care and community organizations to build trustworthy collaborations: knowing oneself (leading from within), knowing one another and being able to develop equitable collaboration (leading together), and knowing the purpose of the collaboration (leading for outcomes).

Changes in Physical Health After Supported Housing: Results from the Collaborative Initiative to End Chronic Homelessness
J. Tsai, L. Gelberg, & R.A. Rosenheck
Journal of General Internal Medicine
This observational multi-site study of a comprehensive supported housing program among chronically homeless adults found reduced number of medical problems and receipt of more preventive procedures but no improvements in physical health-related quality of life.

Role of Health Information Technology in Addressing Health Disparities: Patient, Clinician, and System Perspectives
X. Zhang, B. Hailu, D.C. Tabor, et al.
Medical Care
This paper summarizes the recommendations from a May 2017 scientific workshop focused on “Addressing Health Disparities with Health Information Technology.” One recommendation focused on the need for more research on how health IT can be used to evaluate and address the social determinants of health.


Bridging Gaps to Build Healthy Communities: Opportunities to Better Address Social Determinants to Improve Health
Anthem Public Policy Institute and Quid
Using data from news articles, academic papers, and individuals’ posts and comments from patient forums, the authors of this report examine how social determinants of health are perceived by individuals compared to the dominant viewpoints found in academic research and the media. While researchers and journalists tend to frame health outcomes through structural factors like education and income level, individuals emphasize more immediate influences on their health and health care like adequate support from family and access to care.

Achieving Health Equity and Wellness for Medicaid Populations: A Case Study of Community-Based Organization (CBO) Engagement in the Delivery System Reform Incentive Payment (DSRIP) Program
E. Breslin, H. Arthur, & D. Heaphy
This issue brief highlights current and potential barriers to effective collaboration between CBOs and health care organizations based on the perspective of CBOs in New York and Massachusetts.

Complex Construction: A Framework for Building Clinical-Community Partnerships to Address Social Determinants of Health
G.C. Burke, K. Ramos-Callan, & C. Shearer
United Hospital Fund
This report describes a framework United Hospital Fund has prepared to help primary care providers screen their patients for social determinants of health and partner with CBOs that can respond to those needs. The framework provides guidance on selecting a screening tool, developing a realistic workflow, identifying appropriate CBO partners, and building and maintaining those new relationships.

Partnerships, Programs, and Platforms: Addressing Social Determinants of Health through Multi-Sector Data Sharing
National Interoperability Collaborative
This report provides an overview of the technology behind emerging multi-sector initiatives to address the social determinants of health and improve well-being.

Medical-Legal Partnerships Serving Veterans: History, Growth & Progress
J. Theiss, J.Trott, & A. Peterson
National Center for Medical-Legal Partnership
This issue brief provides a look at the state of the MLPs in Veterans Affairs facilities – why and how legal services have grown in VA Medical Centers, where VA MLPs are operating today, and considerations for the future.