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March 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

Association Between Access to Social Service Resources and Cardiometabolic Risk Factors: A Machine Learning and Multilevel Modeling Analysis
S.A. Berkowitz, S. Basu, A. Venkataramani, G. Reznor, E.W. Fleegler, & S.J. Atlas
BMJ Open
This analysis of the relationship between availability of social service resources and cardiometabolic risk factors found that higher availability of food, employment, and nutrition resources was associated with lower BMI scores, but not systolic blood pressure, cholesterol, or HbA1c levels.

Identifying Patients Experiencing Homelessness in an Electronic Health Record and Assessing Qualification for Medical Respite: A Five-Year Retrospective Review
D.J. Biederman, F. Modarai, J. Gamble, et al.
Journal of Health Care for the Poor and Underserved
This paper describes four methods for using electronic health record data to identify people experiencing homelessness following a hospital encounter in order characterize people who would qualify for a medical respite program.

Social Determinants of Health Priorities of State Medicaid Programs
D.J. Chisolm, D.L. Brook, M.S. Applegate, & K.J. Kelleher
BMC Health Services Research
Based on a survey of 17 state Medicaid medical directors and interviews with 14, this paper finds that Medicaid leaders recognize the importance of SDH in improving health, health equity, and health care costs for the Medicaid population but face challenges implementing social needs interventions.

Facilitators and Barriers to Supplemental Nutrition Assistance Program Incentive Use: Findings from a Clinic Intervention for Low-Income Patients
A.J. Cohen, K.E. Oatmen, M. Heisler, et al.
American Journal of Preventive Medicine
Low income patients who received a primary-care based informational intervention to facilitate use of a SNAP benefit incentive program at farmers' markets reported that use of the program was facilitated by the intervention, along with a desire to eat healthfully and stretch SNAP benefits. Barriers to incentive use included lack of transportation, limited market locations/hours, and confusion regarding how to access the incentive.

From Clinic to Classroom: A Community Health Center-Based Program to Assist Families in Accessing Pre-K in New York City
Hoffman A, Stange M, Hackley B, Kavanaugh M, Machuca H, Shapiro A
Journal of Health Care for the Poor and Underserved
This paper describes a community health center-based outreach program designed to help families apply to and enroll in free Pre-Kindergarten programs in order to leverage medical homes as a site to promote early education enrollment.

Adjusting for Social Risk Factors Impacts Performance and Penalties in the Hospital Readmissions Reduction Program
K.E. Joynt Maddox, M. Reidhead, J. Hu, et al.
Health Services Research
This risk adjustment analysis found that adding social risk factors to the standard risk adjustment model used by Medicare's Hospital Readmissions Reduction Program (HRRP) reduced readmissions penalties to safety-net hospitals by $17 million.

Embedding an Immigration Legal Navigator in a Primary Care Clinic
S. Kimball, M. Maju, N. Singh, & L. Sonis
Annals of Family Medicine
This paper describes a primary care pilot program that uses an AmeriCorps member to help patients navigate the US' complex immigration system through referrals to community immigration legal programs and legal advocacy.

Intimate Partner Violence
E. Miller & B. McCaw
New England Journal of Medicine
This review paper highlights the evidence around best practices for identifying and responding to intimate partner violence in the health care system.

Impact of Supportive Housing on Substance Use-Related Health Care Utilization Among Homeless Persons Who are Active Substance Users
S.A. Miller-Archie, S.C. Walters, T.P. Singh, & S. Lim
Annals of Epidemiology
This evaluation of a supportive housing program for active substance users experiencing chronic homelessness found that individuals placed in supportive housing had lower rates of substance use disorder-related ED visits and hospitalizations than those not placed in the program. Those in supportive housing were also more likely to initiate outpatient substance use treatment.

From Their Perspective: The Connection Between Life Stressors and Health Care Service Use Patterns of Homeless Frequent Users of the Emergency Department
M. Moore, K.M. Conrick, A. Reddy, A. Allen, & C. Jaffe
Health & Social Work
This qualitative study found that frequent ED users experiencing homelessness reported an identifiable pattern of ED use often centered on a crisis event and highlighted the benefits of a social work case management intervention.

Loneliness in Primary Care Patients: A Prevalence Study
R.A. Mullen, S. Tong, R.T. Sabo, et al.
Annals of Family Medicine
This study of the prevalence of loneliness in primary care patients found that 20% of patients in two diverse practice-based research networks were lonely and that loneliness was associated with worse health outcomes and greater health care utilization.

Determining Food-Insecure Families' Resource Access with Health System and Public Data
D. Palakshappa, D. Strane, H. Griffis, & A.G. Fiks
Journal of Health Care for the Poor and Underserved
In this article, EHR data from nine practices was merged with publicly accessible food resource information to map where food-insecure families live, describe families' access to local resources, and identify regions where gaps in services exist.

Geographic Characteristics of Loneliness in Primary Care
S. Tong, R.A. Mullen, C.J. Hochheimer, et al.
Annals of Family Medicine
This study of primary care practices in Colorado and Virginia found that zip codes with higher patient loneliness scores had higher proportions of Black residents and higher unemployment, worse access to health care, lower income, and worse transportation.

Impact of Risk Stratification on Referrals and Uptake of Wraparound Services that Address Social Determinants: A Stepped Wedged Trial
J.R. Vest, N. Menachemi, S.J. Grannis, et al.
American Journal of Preventive Medicine
This pilot study in an urban safety-net setting found that a risk-stratification tool increased referrals to and uptake of wraparound services to address social needs.

A Review of Housing and Food Intersections: Implications for Nurses and Nursing Research
L. Vold, M. Lynch, & W. Martin
Canadian Journal of Nursing Research
This scoping review of the intersection between housing and food security interventions identified three major recommendations for nursing practice and research: primary care screening for low-income groups, enhancing social housing, and challenging housing affordability standards.

Automatically Identifying Social Isolation from Clinical Narratives for Patients with Prostate Cancer
V.J. Zhu, L.A. Lenert, B.E. Bunnell, J.S. Obeid, M. Jefferson, & C.A. Hughes-Halbert
BMC Medical Informatics & Decision Making
This paper describes an effective natural language processing strategy for using clinical narrative data to identify patients who are socially isolated.


California Improvement Network Stories from the Field: Social Needs Screening and Referral Models
California Health Care Foundation
This case study series presents learnings from four diverse health care organizations and early adopters of social needs screening and referral programs.

Socially Vulnerable Older Adults & Medical-Legal Partnership
L. Tobin Tyler
National Center for Medical Legal Partnership
This report describes the unique legal needs facing older adults and ways medical-legal partnerships can improve their care and well-being, with examples from three medical-legal partnership programs serving older adults.

Addressing Social Isolation to Improve the Health of Older Adults: A Rapid Review
S. Veazie, J. Gilbert, K. Winchell, R. Paynter, & J.M. Guise
Agency for Healthcare Research and Quality
This AHRQ-commissioned rapid review of interventions targeting social isolation and loneliness found that physical activity interventions showed the most promise at improving the health of older adults; however, the effects were inconsistent and short-term.