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March Research Round-Up

We are trying something new this month: articles, reports, and commentaries are organized by topic, rather than being listed alphabetically. Like this better? Like it less? Let us know: Send an email to

Screening validity, acceptability, and implementation

Provision of Utility Shut-Off Protection Letters at an Urban Safety-Net Hospital, 2009-2018
P. Giraldo, H.E. Hsu, E.M. Ashe, et al.
Journal of Ambulatory Care Management
Among safety-net hospital patients who received a utility shut-off protection letter, only 16% screened positive for difficulty paying utility bills. Findings raise questions about the validity of utility risk screening.

Initiating and Implementing Social Determinants of Health Data Collection in Community Health Centers
I. Gruß, A. Bunce, J. Davis, K. Dambrun, E. Cottrell, & R. Gold
Population Health Management
Effective integration of EHR-based SDH screening in 8 community health centers in 5 states was facilitated by external incentives and motivators; the presence of an SDH screening advocate; and flexible approaches to clinic screening workflows.

A Review of Tools to Screen for Social Determinants of Health in the United States: A Practice Brief
M. Moen, C. Storr, D. German, E. Friedmann, & M. Johantgen
Population Health Management
This paper summarizes and compares 9 commonly-used social risk screening tools and provides practice, policy, and research recommendations to improve screening.

Screening for Social Determinants of Health Among Children: Patients' Preferences for Receiving Information to Meet Social Needs and a Comparison of Screening Instruments
B.J. Oldfield, M. Casey, A. DeCew, S.I. Morales, & D.P. Olson
Population Health Management
Parents (n=154) and adolescents (n=21) surveyed in a community health center preferred receiving information about resources through technology and printouts rather than meeting with a care coordinator. Parent/adolescent pairs (n=19) had high concordance (>80%) for screening results for both the AHC and the WE CARE tools. The AHC tool generated more positive screens than WE CARE for housing and food insecurity; the converse was true for utility insecurity.

Screening and referral interventions

Integrating Social Needs Screening and Community Health Workers in Primary Care: The Community Linkage to Care Program
K.P. Fiori, C.D. Rehm, D. Sanderson, et al.
Clinical Pediatrics
This study of social services uptake in an urban pediatric practice found that 43% of households screening positive for a social need reported successful referrals. More outreach encounters and a longer follow-up period were associated with referral success.

Effects of In-Person Assistance vs Personalized Written Resources About Social Services on Household Social Risks and Child and Caregiver Health: A Randomized Clinical Trial
L.M. Gottlieb, N.E. Adler, H. Wing, et al.
JAMA Network Open
This randomized trial revealed no significant differences between providing in-person assistance and individualized written information about social resources on outcomes including social risk and child and caregiver health. In an accompanying invited commentary, authors Arvin Garg, Elena Byhoff and Mikayla Gordon Wexler highlight implementation considerations and other outcomes that future studies could measure.

Addressing Social Determinants of Health Within Healthcare Delivery Systems: A Framework to Ground and Inform Health Outcomes
D. Gurewich, A. Garg, & N.R. Kressin
Journal of General Internal Medicine
The authors present the OASIS (Outcomes from Addressing SDoH in Systems) conceptual framework to map the pathways by which unmet social need screening and referral interventions may impact outcomes.

How New Mexico’s Community Health Workers are Helping to Meet Patients’ Needs: Will Tackling Entrenched Problems Like Poverty and Criminal Recidivism Improve Health?
S. Klein, M. Hostetter, R. Tikkanen, & D. McCarthy
The Commonwealth Fund
This case study describes ways CHWs have been deployed in New Mexico to promote health and tackle social challenges, including unemployment and criminal recidivism.

Provision of Social Services and Health Care Quality in US Community Health Centers, 2017
A.M. Kranz, A. Mahmud, D. Agniel, C. Damberg, & J.W. Timbie
American Journal Public Health
A survey of CHCs in 12 states and DC found that on-site social needs assistance provided by CHCs was most often for food insecurity, interpersonal violence, and housing issues. On-site provision of social services was associated with better health care quality.

Putting Learning into Practice to Innovate and Improve Patient Services: A Case Study of Seattle Children’s Hospital
K. Fisher, J. Foti, & J. Povick
Health Leads
This case study describes efforts at Seattle Children’s Hospital to identify and address the social needs of patients & families.

Complex care interventions

Impact of Complex Care Management on Spending and Utilization for High-Need, High-Cost Medicaid Patients
B.W. Powers, F. Modarai, S. Palakodeti, et al.
American Journal of Managed Care
This randomized trial of a CHW-driven complex care management program found a spending reduction of $7,732 per patient per year among high-need, high-cost Medicaid patients compared to usual care, driven primarily by decreases in inpatient utilization. See also this CHCS blog post by Allison Hamblin and Rachel Davis comparing the results of this study to those of the recent RCT of the Camden Coalition model.

Social domain-specific interventions

Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System
National Academies of Sciences, Engineering, and Medicine
This consensus report summarizes the evidence base, explores how social isolation and loneliness affect health and quality of life in adults aged 50 and older, and makes recommendations for health care settings.

Food Insecurity Among Veterans: Resources to Screen and Intervene
A.J. Cohen, J.L. Rudolph, K.S. Thomas, et al.
Federal Practitioner
The authors describe the Veterans Health Administration's approach to identifying and addressing food insecurity among its patients, including an EHR-based reminder to screen, an interdisciplinary team-based model, and community partnerships.

Food Insecurity and Health: Overcoming Food Insecurity Through Healthcare-Based Interventions
National Quality Forum & Humana
This guide details a range of strategies that healthcare organizations can tailor to different contexts to enhance food insecurity interventions.

Homeless Special Needs Plans for People Experiencing Homelessness
S.H. Jain, J. Baackes, & J.J. O’Connell
The authors of this perspective piece argue for the creation of a homelessness-focused special needs plan, a type of Medicare Advantage insurance plan aimed at meeting the unique care needs of specific high-need populations, as a means of sustainably financing health care delivery for homeless individuals.

"From Taboo to Routine": A Qualitative Evaluation of a Hospital-Based Advocacy Intervention for Domestic Violence and Abuse
S. Dheensa, G. Halliwell, J. Daw, S.K. Jones, & G. Feder
BMC Health Services Research
This qualitative evaluation of Independent Domestic Violence Advisors found that they enabled providers to immediately refer and provide support to patients who might otherwise have been lost along a referral pathway. Facilitators such as training and dedicated space were seen as key to successful implementation.

Improving the Healthcare Response to Domestic Violence and Abuse in UK Primary Care: Interrupted Time Series Evaluation of a System-Level Training and Support Programme
A.H. Sohal, G. Feder, K. Boomla, et al.
BMC Medicine
This interrupted time series analysis of data from five London boroughs found that general practices that received integrated referral routes, training, and system-level support reported increased referrals to domestic violence service providers.

Additional publications

Fostering Healthy Neighborhoods: Alignment Across the Community Development, Financial Well-Being and Health Sectors
Build Healthy Places Network, Prosperity Now, & Financial Health Network
This brief presents examples of existing alignment across sectors, opportunities and challenges for increased collaboration, and recommendations to foster cross-sector alignment.

Addressing Social Determinants: Scaling Up Partnerships with Community-Based Organization Networks
L. Robertson & B. Chernof
Health Affairs Blog
This blog post argues for the development of a national network of CBOs that serve as hubs for local cross-sector partnerships.

Status of Health Equity Report
The Root Cause Coalition
This report outlines actionable strategies to improving health equity by addressing social risks based on a survey of primary care providers and interviews with representatives from hospitals and health care systems, payers, funders, and community-based organizations.

Social Spending to Improve Population Health - Does the United States Spend as Wisely as Other Countries?
R.S. Tikkanen & E.C. Schneider
The New England Journal of Medicine
This perspective piece compares social spending patterns in the U.S. and other countries and implications for population health.