The SIREN Podcast (Social Interventions Research and Evaluation Network)

On December 3rd, 2021, SIREN organized a special closing event (insert tears) for the 2021 Coffee & Science series. Special guests Bethany Hamilton, JD, and Kelly Doran, MD, shared their own takeaways from the series and asked participants to share favorite episodes and raise big-picture questions about how social care research can be used to move the needle on policy and practice. 

Reminder! Please let us know what you thought of Coffee & Science and your ideas for SIREN’s 2022 National Research Meeting: https://ucsf.co1.qualtrics.com/jfe/form/SV_7Otc9vpAIr8G9cW 

Voices you hear, in order of appearance:

• Yuri Cartier, MPH, Senior Research Associate at SIREN
• Kelly Doran, MD, Emergency Physician and Assistant Professor of Emergency Medicine and Population Health at NYU Grossman School of Medicine
• Laura Gottlieb, MD, MPH, Founding Co-Director of SIREN
• Bethany Hamilton, JD, Co-Director of the National Center for Medical-Legal Partnership at George Washington University

Episodes highlighted in this wrap party:

• Challenging Racist Systems, Processes, and Analyses in Social Care
• To Scale or Not to Scale: Social Risk Screening and the US Health Care System
• The Intersection of Racism, Discrimination, and Social Risk Screening in Clinical Settings
• Why and How a Health Center Created a Social Enterprise
• Community-Hospital Collaborations to Improve Neighborhoods
• The Health Care Anchor Model
• Delivering Social Care in the Virtual Frontier
• Community Health Workers and Social Care Integration
• Using Clinical Decision Support Tools to Contextualize Care
• Taking Action on Housing as a Political Determinant of Health

Other resources:

• NASEM Framework

In this episode, we are joined by Cherelle Vanbrakle, MEd, the Director of Health Promotion and Community Advocacy at People’s Community Clinic based in Austin, TX, and Andrea Nederveld, MD, MPH, an Assistant Professor in the Department of Family Medicine at the University of Colorado, to discuss the state of the science about the implementation of social screening in healthcare settings.

To read the SIREN social screening report and a bevy of related resources, visit the SCREEN Report webpage.

People’s Community Clinic: https://www.austinpcc.org/about-us-2/

Research by Dr. Nederveld, noted in podcast: 

Nederveld AL, Duarte KF, Rice JD, Richie A, Broaddus-Shea ET. IMAGINE: A trial of messaging strategies for social needs screening and referral. Am J Prev Med. 2022;63(3, Supplement 2):S164-S172. https://doi.org/10.1016/j.amepre.2022.04.025 https://www.ajpmonline.org/article/S0749-3797(22)00252-5/fulltext

Broaddus-Shea ET, Fife Duarte K, Jantz K, Reno J, Connelly L, Nederveld A. Implementing health-related social needs screening in western Colorado primary care practices: Qualitative research to inform improved communication with patients. Health Soc Care Community. 2022;10.1111/hsc.13752. doi:10.1111/hsc.13752 PMID: 35170822 

https://onlinelibrary.wiley.com/doi/10.1111/hsc.13752 

This bonus episode is a special addendum to the first five episodes, which all focused on health care sector efforts to increase Awareness about both patient and community-level social conditions. Laura Gottlieb, MD, MPH, SIREN Director and Associate Professor of Family and Community Medicine at UCSF chats with SIREN Advisor Eric Fleegler, MD, MPH, Assistant Professor of Pediatrics and Emergency Medicine at Harvard Medical School and pediatric emergency physician at Boston Children’s Hospital. They and other participants in the lively Zoom meeting brought up questions such as:

• What’s changed in the last 13 years with clinic-based social risk screening?
• Should you screen for a social need when you don’t have a resource to meet the need?
• What can smoking cessation teach us about social risk screening?
• Should we ask patients if they want assistance instead of screening?

Recommended references:

• Cullen D, Abel D, Attridge M, Fein JA. Exploring the gap: food insecurity and resource engagement. Academic Pediatrics. 2021.
• De Marchis EH, Alderwich H, Gottlieb LM. Do Patients Want Help Addressing Social Risks? JABFM. March 2020.
• De Marchis EH, Ettinger de Cuba S, Chang L, et al. Screening Discordance and Characteristics of Patients With Housing-Related Social Risks. Am J Prev Med. 2021.
• Fritz CQ, Thomas J, Brittan MS, Mazzio E, Pitkin J, Suh C. Referral and resource utilization among food insecure families identified in a pediatric medical setting. Acad Pediatr. 2021.
• Hassan A, Scherer EA, Pikcilingis A, et al. Improving social determinants of health: effectiveness of a web-based intervention. Am J Prev Med. 2015.
• Sandoval VS, Jackson A, Saleeby E, et al. Associations Between Prenatal Food Insecurity and Prematurity, Pediatric Health Care Utilization, and Postnatal Social Needs. Acad Pediatr. 2021.

This episode features a conversation between Lucia Rojas-Smith, DrPH, MPH, Director of the Center for Community Health Evaluation and Economic Research at RTI and Shannon O’Connor, PhD, MS, MA, a social science research analyst at the Center for Medicare and Medicaid Innovation. This session is the fourth in a series focused on health care sector efforts to provide Assistance to patients to reduce their social risks. Drs. Rojas-Smith and O’Connor discussed findings from the Accountable Health Communities (AHC) Model’s first annual report. 

Recommended references:

• Accountable Health Communities (AHC) Model Evaluation. First Evaluation Report. 2020.
• CMS. Building strong community partnerships to address social needs: a case study in effective advisory board collaboration from the Accountable Health Communities model. 2021.
• Holcomb et al. Developing and evaluating a quality improvement intervention to facilitate patient navigation in the Accountable Health Communities model. Front Med. 2021.
• Gottlieb et al. Evaluating the Accountable Health Communities demonstration project. J Gen Intern Med. 2017.

On March 29, 2024, the Harvard Medical School Center for Bioethics convened a session of the Organizational Ethics Consortia Series on social care. Addressing health inequity generally requires attention to the most marginalized patients, whose health is often undermined by social, legal and financial challenges. In response, many health care delivery organizations have begun to collect data about health-related social needs and build organizational capacity to address these needs, either “in-house” or through partnerships with community-based organizations. This gives rise to challenging ethical questions:

• How do we weigh the potential benefits and harms of screening for social needs? And what responsibilities do health care delivery organizations have once they have health-related social need information?
• How should health care delivery organizations allocate their resources between addressing specific patient needs versus thinking more broadly about community-level social determinants? 

Presenters:

Monica E. Peek, MD, MPH, MSc, Ellen H. Block Professor of Health Justice, Section of General Internal Medicine; Associate Vice-Chair for Research Faculty Development, Dept of Medicine; Associate Director, Chicago Center for Diabetes Translation Research; Dir. of Research (Assoc. Director), MacLean Center for Clinical Medical Ethics; Executive Medical Director, Community Health Innovation

Marshall Chin, MD, MPH, Richard Parrillo Family Distinguished Service Professor of Healthcare Ethics in the Department of Medicine, University of Chicago; Associate Director, MacLean Center for Clinical Medical Ethics; Co-Director, Robert Wood Johnson Foundation Advancing Health Equity: Leading Care, Payment, and Systems Transformation National Program Office; Co-Chair, CMS Health Care Payment Learning and Action Network Health Equity Advisory Team

Laura Gottlieb, MD, MPH, Co-director, Social Interventions Research and Evaluation Network (SIREN); Professor, Department of Family and Community Medicine, University of California, San Francisco

Moderator:

Lauren A Taylor, PhD, MDiv, Assistant Professor, NYU Grossman School of Medicine

Consortium Co-Chair:

Charlotte H. Harrison, PhD, JD, MPH, HEC-C, Co-Chair, Organizational Ethics Consortium, Harvard Medical School Center for Bioethics; Immediate Past Hospital Ethicist and Director, Office of Ethics, Boston Children’s Hospital

This consortia series provides a forum for local, national, and international discussion of organizational-level ethical issues and processes to address them, with the aim of cultivating a learning community of practitioners and scholars in this evolving field. We are grateful to the Harvard Medical School Center for Bioethics for making this recording available to the SIREN Podcast audience. To learn more, visit https://bioethics.hms.harvard.edu/ 

Sarah DeSilvey, DNP, FNP-C, social determinants of health clinical informatics director of the Gravity Project and faculty at the University of Vermont Larner College of Medicine speaks with Michael Bailit, MBA, founder of Bailit Health, a consulting firm dedicated to ensuring insurer and provider performance accountability. This conversation is the fourth in a series focused on health care sector efforts to increase Awareness about both patient and community-level social conditions. Sarah and Michael share design considerations from state Medicaid agencies weighing the use of quality measures for social risk screening.

Recommended references:

• Bailit Health. Developing a Social Risk Factor Screening Measure. 2020.
• Bailit Health. Social Risk Factor Screening in Medicaid Managed Care. 2020.
• Alderwick H, Gottlieb LM. Meanings and misunderstandings: A social determinants of health lexicon for health care systems. Milbank Q. 2019.
• The Gravity Project 
• Gottlieb L, DeSilvey SC. New Clinical Coding Guidelines Account for Patients’ Social Risk: We Should Do More to Ensure They Advance Health Care Quality and Equity. Health Affairs Blog. 2020.

On Monday March 11th participants joined us for a conversation about the new SIREN Social Care Conceptual Model! Emerging evidence suggests that social care programs do not affect health solely by connecting patients with social services and reducing socioeconomic barriers. In a recent paperwe used this evidence to develop a model that depicts the multiple pathways through which social care interventions appear to operate. SIREN co-directors Laura Gottlieb, Danielle Hessler, and Caroline Fichtenberg discussed the new model and its implications for future program investments and evaluations. 

Want to jump into the conversation? Join us at the Feb 2025 SIREN National Research Meeting: Advancing the Science of Social Care. Learn more at: https://sirenetwork.ucsf.edu/2025-national-research-meeting. 

This season of the SIREN Podcast is supported by Kaiser Permanente.  

This episode features a conversation between Nessia Berner Wong, MPH, Senior Policy Analyst at Change Lab Solutions, and Lauren Poor, MPH, a Regional Program Manager with the Healthy Food in Health Care program at Health Care Without Harm. This is the fifth in a series of six Coffee & Science events on topics related to Alignment and Advocacy, which are both about what health care can do at the community level to address social conditions. This conversation explores Healthcare without Harm’s Anchors in Resilient Communities initiative and how health care organizations can support sustainable food procurement and employment opportunities. 

Recommended references:

• Anchors in Resilient Communities. ARC Resource Library (website).
• Healthcare Anchor Network. Case study: Anchors in Resilient Communities. 2020.
• ChangeLab Solutions. Legal & Policy Strategies for Health Care & Food System Partners. 2021.
• ChangeLab Solutions webinar. Food Procurement for a More Just Food System. June 2020.

What is this conversation series all about? What are the “five As” of social and medical care integration? How is the COVID-19 pandemic changing how health care systems see their roles and responsibilities related to the integration of social and medical care delivery? SIREN Director Dr. Laura Gottlieb introduces SIREN’s new biweekly conversation series and interviews Dr. Kirsten Bibbins-Domingo, Professor and Chair of the Department of Epidemiology and Biostatistics, Vice Dean for Population Health and Health Equity in the UCSF School of Medicine, and Chair of the National Academy of Medicine Ad-Hoc Committee on Integrating Social Needs Care into the Delivery of Health Care.

This episode is the first in a set of six Coffee and Science conversations on Assistance—health care sector activities that aim to reduce social risk by providing or linking patients with relevant social services. Nadia Islam, PhD, an associate professor in the Department of Population Health at NYU Langone, speaks with Maria Lemus, the executive director of Visión y Compromiso, an organization created and led by promotores that supports work to improve both individual and community wellbeing. Nadia and Maria explore the potential risks and benefits of formalizing roles for community health workers and promotores in the health care sector’s social care workforce.

Recommended references:

• Visión y Compromiso. Key Workforce Priorities for the Community Transformation Model. 2017.
• Islam N, Shapiro E, Wyatt L, Riley L, Zanowiak J, Ursua R, et al. Evaluating community health workers’ attributes, roles, and pathways of action in immigrant communities. Prev Med. 2017.
• Islam N, Rogers ES, Schoenthaler A, Thorpe LE, Shelley D. A cross-cutting workforce solution for implementing community–clinical linkage models. Am J Public Health. 2020.
• Peretz PJ, Islam N, Matiz LA. Community Health Workers and Covid-19 — Addressing Social Determinants of Health in Times of Crisis and Beyond. N Engl J Med. 2020.

The final panel at the SIREN 2022 National Research Meeting: Racial Health Equity in Social Care featured four Experts by Experience (Lisa Hamlett, Mike McNear, Ann Reynoso, and Stephanie Walker) as they reflected on their takeaways from the meeting, expressed what was most important to them, and pointed out opportunities for more research and action. The goal of this session was for participants to leave the SIREN National Research Meeting feeling grounded in what mattered to patients with lived experience of racism and socioeconomic challenges, fired up about working in ways that actively promote racial health equity, and focused on what comes next. The panel was moderated by Tanissha Harrell and Rebekah Angove.

This episode features a conversation between Emmy Ganos, PhD, Senior Program Officer at the Robert Wood Johnson Foundation and Stacie Dusetzina, PhD, Associate Professor of Health Policy and Ingram Associate Professor of Cancer Research at Vanderbilt University Medical Center. This session is the last of four talks focused on health care sector efforts to Adjust clinical care based on information about patients’ social circumstances. In this conversation, Emmy and Stacie dive into the implications of real-time pharmacy benefit tools and explore what we know about patient and provider preferences when it comes to conversations about medication costs.

Recommended references:

• Everson J, Frisse ME, Dusetzina SB. Real-Time Benefit Tools for Drug Prices. JAMA. 2019.
• Doshi JA, Li P, Huo H et al. Association of Patient Out-of-Pocket Costs with Prescription Abandonment and Delay in Fills of Novel Oral Anticancer Agents. J Clin Oncol. 2018.
• Sloan CE, Ubel PA. The 7 Habits of Highly Effective Cost-of-Care Conversations. Annals Intern Med supplement issue on cost-of-care conversations. 2019.
• America’s Essential Hospitals. Cost of Care Conversations Resources. Web collection.

SIREN Senior Research Associate Yuri Cartier, MPH, sits down with Kalpana Ramiah, DrPH, MSc, CPH, Vice President of Vice President of Innovation at America’s Essential Hospitals and Director of the Essential Hospitals to discuss SIREN’s recent review of surveys measuring the prevalence of social screening activity in different health care settings in the United States. Dr. Ramiah shares how the review’s findings can be used by essential hospitals, and what other considerations and challenges remain top of mind for her as we head into an era of increased policy incentives and requirements around social screening.

To read the SIREN social screening report and a bevy of related resources, visit the SCREEN Report webpage.

Quick links to references mentioned in this episode:

• The Center for Medicare and Medicaid Services (CMS). Hospital Inpatient Quality Reporting (IQR) measures on social screening: PDF download 
• Essential Hospitals Institute publications:
  • Milestones for Community-Integrated Health Care at Essential Hospitals
  • Patient Trust: A Guide for Essential Hospitals
  • The Role of Essential Hospitals in Combating Structural Racism: An Informational Brief 

This is the first of a two-part webinar series on implications of the Camden Coalition’s RCT results. 

In 2020, a major article on “healthcare hotspotting” may have caught your eye. It did ours! The article described findings from a four-year, prospective, 800-person randomized evaluation of the Camden Coalition’s Camden Core Model, an innovative and comprehensive approach to care coordination for patients with very high use of healthcare services. The study found no differences in hospital utilization between patients randomly assigned to the Camden Core Model and those who received usual care. In 2023, the Camden Coalition published two secondary analyses looking at intervention dosage and engagement, and they teamed back up with MIT’s J-PAL to publish a new analysis looking at more intermediate measures of care coordination. These studies help to explain the original RCT’s primary outcomes findings. 

On April 5, 9-10am PT, participants joined us for a moderated panel discussion with Kathleen Noonan (Camden Coalition), Kedar Mate (Institute for Healthcare Improvement), and Damon Francis (Alameda Health System) about study implications. Prior to the panel conversation, Amy Finkelstein (MIT) and Aaron Truchil (Camden Coalition) briefly presented study findings.

Want to jump into the conversation? Join us at the Feb 2025 SIREN National Research Meeting: Advancing the Science of Social Care. Learn more at: https://sirenetwork.ucsf.edu/2025-national-research-meeting.

This season of the SIREN Podcast is supported by Kaiser Permanente. 

This episode features a conversation between Julia Adler-Milstein, Professor of Medicine and Director of the Center for Clinical Informatics and Improvement Research at the University of California, San Francisco and Tiffany Veinot, Professor of Health Behavior and Health Education cross-appointed at the School of Information and School of Public Health at the University of Michigan. This session is second of four talks focused on health care sector efforts to Adjust clinical care based on information about patients’ social circumstances. In this conversation, Julia and Tiffany explore the emerging discipline of social care informatics and ways informatics can support care adjustment strategies.

Recommended references:

• Computing Community Consortium research agenda. 2018.
• Veinot TC, Ancker JS, Bakken S. Health informatics and health equity: improving our reach and impact. JAMIA (introduction to special issue on health informatics and health equity). 2019.
• Veinot TC, Mitchell H, Ancker JS. Good intentions are not enough: how informatics interventions can worsen inequality. JAMIA. 2018.
• Veinot TC et al. Leveling up: on the potential of upstream health informatics interventions to enhance health equity. Medical Care. 2019. 
• Senteio C, Adler-Milstein J, Richardson C, Veinot TC. Psychosocial information use for clinical decisions in diabetes care. JAMIA. 2019.
• Senteio C, Veinot T, Adler-Milstein J, Richardson C. Physicians’ perceptions of the impact of the EHR on the collection and retrieval of psychosocial information in outpatient diabetes care. Intl J Med Informatics. 2018

Social care practice and research are often inspired by intentions to advance health equity. However, social care is often planned and executed without a clear recognition of and confrontation with the racism, particularly anti-Black racism, that has led to existing inequities. While the legally-sanctioned enslavement of Black people in the United States was abolished in 1865, many of its aims have been perpetuated through residential segregation, the War on Drugs, and the school-to-prison pipeline, to name a few examples. The SIREN National Research Meeting kicked off on September 15, 2022 with a challenge to our moral imagination: In what ways would social care benefit from the contemporary theory and practice of abolition movements in other sectors?

In this opening plenary session, physician, scholar, and thought leader Rhea Boyd facilitated a discussion with legal professor and ethicist Osagie Obasogie and education scholar Darion Wallace. Discussants explored how abolitionist thinking has been applied in other fields, including the legal system and school-based education and ways to re-imagine types of social care that cultivate healing and racial health equity.

Publications mentioned in this session:

• Becoming Abolitionists, by Derecka Purnell
• Torn Apart, by Dorothy Roberts
• The End of Policing, by Alex Vitale
• Pushout, by Monique W. Morris
• “Just what is afropessimism and what’s it doing in a nice field like education?: Unpacking new contributions to Black educational thought”, by C. Darius Gordon

This episode features a conversation between Megan Sandel, MD, MPH, an associate professor of pediatrics at the Boston University Schools of Medicine and Public Health and co-lead principal investigator with Children’s Health Watch, and Rhea Boyd, MD, MPH, a pediatrician, public health advocate, and scholar who is the Director of Equity and Justice for The California Children’s Trust and most recently, co-developed THE CONVERSATION: Between Us, About Us, a national campaign to bring information about the COVID vaccines directly to Black communities. This session is the second in a series focused on health care sector efforts to provide Assistance to patients to reduce their social risks. Megan and Rhea explore the ways in which social inequality has been encoded and medicalized in the conceptualization of social care and challenge us to think differently about what “health equity” means. 

Recommended references:

• Boyd RW, Lindo EG, Weeks LD, McLemore MR. On Racism: A New Standard for Publishing on Racial Health Inequities. Health Affairs Blog. 2020.
• Benjamin R. Race After Technology: Abolitionist Tools for the New Jim Code. Polity. 2019.
• Eubanks V. Automating Inequality: How High-Tech Tools Profile, Police, and Punish the Poor. Picador USA. 2019.
• Krieger N, Boyd RW, De Maio F, Maybank A. Medicine’s Privileged Gatekeepers: Producing Harmful Ignorance About Racism and Health. Health Affairs Blog. 2021.
• Putnam-Hornstein E, Ahn E, Prindle J et al. Cumulative Rates of Child Protection Involvement and Terminations of Parental Rights in a California Birth Cohort, 1999–2017. AJPH. 2021.
• Hooks b. Feminist Theory: From Margin to Center. Routledge (3rd ed). 1984, 2014.
• Barceló N, Shadavran S. Race, Metaphor, and Myth in Academic Medicine. Acad Psychiatry. 2020.

Although there is no question that adverse social circumstances negatively impact health and healthcare outcomes, it is not clear what the healthcare sector’s role should be in addressing these adverse social factors. On February 28, 2024, SIREN Co-Director Caroline Fichtenberg moderated a lively discussion with three thought-leaders on their perspectives on this important question: 

• Seth Berkowitz, MD, MPH, Associate Professor of Medicine, UNC School of Medicine 
• Sherry Glied, PhD, MA, Dean and Professor of Public Service, NYU Wagner School of Public Service 
• Stacy Lindau, MD, MA, Catherine Lindsay Dobson Professor of Obstetrics and Gynecology and Professor of Medicine, University of Chicago School of Medicine

Want to jump into the conversation? Join us at the Feb 2025 SIREN National Research Meeting: Advancing the Science of Social Care. Learn more at: https://sirenetwork.ucsf.edu/2025-national-research-meeting.

This season of the SIREN Podcast is supported by Kaiser Permanente. 

In this episode, Sarah Coombs, the director for health system transformation at the National Partnership for Women & Families, and Janice Tufte, an active patient partner in research, evidence generation, measurement, and care improvement, discuss their reactions to the patient and patient caregiver perspectives section of the State of the Science on Social Screening in Healthcare Settings.

 
To read the SIREN social screening report and a bevy of related resources, visit the SCREEN Report webpage.

References

• Cochrane Consumer - Essentials Training: https://training.cochrane.org/essentials 
• National Center for Complex Care and Social Needs: https://www.nationalcomplex.care/our-work/ 
• BREE Collaborative SdoH Report: https://www.qualityhealth.org/bree/topic-areas/social-determinants-of-health/ 
• Public Agenda: https://www.publicagenda.org/wp-content/uploads/2019/08/itsAboutTrust_UHF_Final.pdf  
• Harvard research on discrimination in health care: https://media.npr.org/assets/img/2017/10/23/discriminationpoll-african-americans.pdf 
• Raising the Bar 

This episode features a conversation between Wylie Liu, MPH, MPA, Executive Director of the Center for Community Engagement at the University of California, San Francisco, and Darlene Oliver Hightower, JD, Vice President, Community Health Equity at Rush University Medical Center. This is the second in a series of six Coffee & Science events on topics related to Alignment and Advocacy, which are the last two “A”s of the National Academy of Medicine’s framework that SIREN’s used to organize Coffee & Science. Alignment and Advocacy are both about what health care can do at the community level to address social conditions. This conversation explores the pillars of Rush’s healthcare anchor institution model and its health equity work.

Recommended references:

• Healthcare Anchor Network Case Study. Rush University Medical Center (RUMC): Collaborating with community stakeholders to improve economic vitality and health. 2021.
• Ubhayakar S et al. Anchor Mission Playbook. Rush University Medical Center and The Democracy Collaborative. 2019.
• Healthcare Anchor Network. Anchor Mission Communications Toolkit. Rush University Medical Center and The Democracy Collaborative. 2020.
• Ansell DA et al. Health Equity as a System Strategy: The Rush University Medical Center Framework. NEJM Catalyst Innovations in Care Delivery. 2021.
• Kanter RM. West Side United: Hospitals Tackle the Racial Health and Wealth Gap. Harvard Business School Case 321-026. 2020.
• Rhee N. “A Second City”. Chicago Magazine. 2018.

Health research remains ensconced in a heavily positivist, reductionist, settler-colonial, racial-capitalist “ritual” of knowledge extractivism and expropriation wherein credentialed researchers mine marginalized communities for data to (re)package and (re)distribute as their (our) own knowledge. Much of this work has focused on racial health inequities while, curiously, leaving unexamined matters of positionality, epistemic equity, and procedural justice in the production and curation of knowledges/narratives about racialized subjects (here, perhaps better described as “objects”). In the US, this production is dominated and curated mostly by White scholars—from tenure-track faculty positions, to funding review panels, to editorial boards, to peer-review bodies. In short, the public/medical health knowledge production and curation enterprise is structurally racist, and it is time that we confront the inherent contradictions of a health equity discourse that fails to interrogate the racialized power dynamics that animate it. Moreover, it is time that we remix the canon and forge a future health research capable of doing our health narratives epistemic—and poetic—justice. 

In this spirit, social epidemiologist and poet Professor Ryan Petteway draws from social epidemiology, critical, critical race, Black feminist, and decolonizing theory literatures to engage poetry as a site of “radical openness and possibility” (hooks)—an inclusive space of resistance for the production of counternarratives within discourse of health (in)equity. 

Dr. Petteway presented two poems at the SIREN 2022 National Research Meeting: Racial Health Equity in Social Care. “Something, Something, Something by Race, 2021” and “RELATIVES//Risks” enact public health critical race praxis (Ford & Airhihenbuwa) principles of “voice” and “disciplinary self-critique” as mode of resistance to counter the epistemic violence of our structurally racist and racial-capitalist health inequities research enterprise. In each poem, Petteway foregrounds considerations of epistemic justice/oppression, data (in)justice, and narrative power—illustrating poetry as praxis to challenge public health’s history of violence against our bodies, its (re)colonization of our lives, and its (a)political silence on matters of epistemic and social injustice. These works suggest the epistemological, ethical, and material imperative of remixing/reimagining health knowledge production, expression, and curation practices to more fully—and unapologetically—"center the margins,” with poetry a necessary format of health equity discourse for resistance and healing.

Poems:

"something something something by race, 2021" Available here.

"RELATIVES//Risks" Available here.

This episode features a conversation between Damon Francis, MD, Medical Director of the Homeless Health Center in the Alameda Health System as well as Chief Clinical Officer of Health Leads, and Noha Aboelata, MD, Chief Executive Officer and co-founder of the Roots Community Health Center in Oakland, California. This is the last in a series of six Coffee & Science events on topics related to Alignment and Advocacy, which are both about what health care can do at the community level to address social conditions. This conversation takes a deep dive into Clean 360, an innovative social enterprise launched by Roots to provide employment and skill-building opportunities to formerly incarcerated community members in order to improve their health and well-being. In this thought-provoking conversation, Drs. Francis and Aboelata discuss how Roots came to develop a soap and bath products factory; Dr. Aboelata’s inspiring vision for how community health centers can help address community needs; and ideas for how other types of health care organizations can use their procurement dollars to help improve economic and health outcomes in their communities.

Recommended references:

• Clean 360 online store
• Gottlieb L, Razon N, Aboelata N. How do Community Health Centers Pay for Social Care Programs? SIREN. 2019.
• Roots Community Health Center. Emancipators Initiative (webpage).
• Drummond T. “Out of prison, soapmaking offers a clean start”. Crosscurrents, KALW 91.7 FM. 2016.
• Metzl JM, Roberts DE. Structural Competency Meets Structural Racism: Race, Politics, and the Structure of Medical Knowledge. AMA J Ethics. 2014.

 Dr. Anand Shah, Vice President of Social Health at Kaiser Permanente speaks with Dr. Stacy Lindau, tenured professor at the University of Chicago, founder of NowPow, and president of MAPSCorps. This conversation is the first of several conversations about health care sector efforts to increase Awareness about both patient and community-level social conditions. Dr. Shah and Dr. Lindau share why whole person care matters to them personally and delve into the opportunities and challenges to taking social risk screening to scale. 

Some references mentioned by our speakers in this episode: 

• SIREN Coffee & Science Episode 0  NASEM. Integrating Social Care into the Delivery of Health Care. 2019. 
• CMS 2021 E&M code changes related to social determinants of health 
• Gottlieb LM, Hessler D, Long D, et al. Effects of social needs screening and in-person service navigation on child health: a randomized clinical trial. JAMA Pediatr. 2016:e162521. 
• Tong ST, Liaw WR, Kashiri PL, et al. Clinician experiences with screening for social needs in primary care. J Am Board Fam Med. 2018;31(3):351-363. 
• Lindau ST, Makelarski JA, Abramsohn EM, et al. CommunityRx: A real-world controlled clinical trial of a scalable, low-intensity community resource referral intervention. Am J Public Health. 2019:e1-e7. 
• Wilson JMG, Jungner G, World Health Organization. Principles and practice of screening for disease. 1968. 

Dr. Lindau’s disclosure statement: Under the terms of Grant Number 1C1CMS330997-01-00 (Lindau, PI) from the Department of Health and Human Services, Centers for Medicare & Medicaid Services we were expected to develop a sustainable business model which will continue and support the model that we tested after award funding ends. I am the founder and owner of a social impact company NowPow, LLC and president of MAPSCorps, 501(c)(3). Neither the University of Chicago nor UChicago Medicine is endorsing or promoting NowPow or its business, products, or services. I will not discuss off label use or investigational use in my presentation. 

This episode features a conversation between Reginald Williams II, Vice President of International Health Policy and Practice Innovations at the Commonwealth Fund, and Matt Pantell, MD, MS, a pediatric hospitalist, assistant professor of pediatrics at UCSF, and SIREN researcher. This session is the third in a series focused on health care sector efforts to provide Assistance to patients to reduce their social risks. Reggie and Matt define social isolation and loneliness and explore different approaches used in the UK, Norway, and elsewhere to mitigate loneliness and social isolation.

Recommended references:

• Tung E, De Marchis E, Gottlieb L, Lindau S, Pantell M. Patient experiences with screening and assistance for social isolation in primary care settings. J Gen Intern Med. 2021 Feb 2;1-7.  
• National Academies of Sciences, Engineering, and Medicine. Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. Washington, DC: National Academies Press; 2020.
• National Institute on Aging. Social Isolation and Loneliness Toolkit - An outreach toolkit to reduce social isolation and loneliness. Webpage.
• National Suicide Prevention Lifeline - National network of local crisis centers that provides emotional support to people in emotional distress or crisis. Telephone: 1-800-273-8255; Website: https://suicidepreventionlifeline.org 
• Friendship Line: Serves as both a crisis intervention hotline and a warmline for non-emergency emotional support calls for adults 60 years and older. Telephone: 1-800-971-0016; Web site: https://www.ioaging.org/services/all-inclusive-health-care/friendship-line 
• National Alliance on Mental Illness Helpline: Hotline that provides resources and support to people living with mental health conditions as well as their family and caregivers. Telephone: 1-800-950-NAMI (6264); Web site: https://nami.org/help

Each year an increasing number of original research articles are published about healthcare-based social care programs and policies. However, relatively few of these studies measure the impact of social care interventions on different racial or ethnic minority groups. More information about differential impacts could help to improve the implementation – and ideally the impacts – of social care. During the SIREN 2022 National Research Meeting: Racial Health Equity in Social Care, physician scientists Crystal Cené and Monica Peek briefly shared findings from a recent review they co-led, funded by the Patient Centered Outcomes Research Institute (PCORI), which involved a collaboration with researchers from both RTI and SIREN. Drs. Peek and Cené in this fireside chat explored what counts as measuring racial health equity (including how they developed a novel framework on “thoughtfulness” and “informativeness”), how much (or little) racial health equity has been explicitly described or measured in the social care interventions evidence base to date, and concrete next steps for researchers and practitioners that can strengthen the racial health equity implications of their work. 

Reference:

Cené CW, Viswanathan M, Fichtenberg CM, et al. Racial health equity and social needs interventions: a review of a scoping review. JAMA Netw Open. 2023;6(1):e2250654. doi:10.1001/jamanetworkopen.2022.50654

This episode is the final in a series of five conversations focused on health care sector efforts to increase Awareness about both patient and community-level social conditions. Minal Patel, PhD, MPH, an associate professor of health behavior and health education at the University of Michigan School of Public Health, speaks with Emilia De Marchis, MD, MAS, an assistant professor in the Department of Family and Community Medicine at the University of California San Francisco, a family physician, and a member of the SIREN research team. Minal and Emilia explore a wide range of reasons why patients who screen positive for a social risk may not desire related assistance from the health care team. They also discuss how staff and provider training might influence patient interest in assistance interventions.

Recommended references:

• Alderwick H, Gottlieb LM. Meanings and misunderstandings: A social determinants of health lexicon for health care systems. Milbank Q. 2019.
• De Marchis EH, Alderwich H, Gottlieb LM. Do Patients Want Help Addressing Social Risks? JABFM. March 2020.
• De Marchis EH, Hessler D, Fichtenberg C, et al. Assessment of Social Risk Factors and Interest in Receiving Health Care–Based Social Assistance Among Adult Patients and Adult Caregivers of Pediatric Patients. JAMA Netw Open. Oct 2020.
• Devoe JE. When and How Do We Need Permission to Help Patients Address Social Risk? JABFM. March 2020.
• Patel MR, Heisler M, Piette JD, et al. Study protocol: CareAvenue program to improve unmet social risk factors and diabetes outcomes- A randomized controlled trial. Cont Clin Trials. Feb 2020.
• Patel MR, Resnicow K, Lang I, et al. Solutions to Address Diabetes-Related Financial Burden and Cost-Related Nonadherence: Results From a Pilot Study. Health Educ Behav. 2017. 
• Parkinson MD, Hammonds T, Keyser DJ, et al. Impact of Physician Referral to Health Coaching on Patient Engagement and Health Risks: An Observational Study of UPMC’s Prescription for Wellness. Am J Health Promot. Feb 2020.

Dr. Toyin Ajayi, Co-founder and Chief Health Officer at Cityblock Health speaks with Dr. Monica Peek, associate professor of General Internal Medicine at the University of Chicago. This conversation is the second in a series focused on health care sector efforts to increase Awareness about both patient and community-level social conditions. Drs. Ajayi and Peek discuss concerns structurally marginalized people may have in spaces like health care in and outside the context of social risk screening and explore ways health care organizations can earn trust and build rapport with patients of color.

Recommended references:

• Peek ME, Odoms-Young A, Quinn MT et al. Racism in healthcare: Its relationship to shared decision-making and health disparities: A response to Bradby. Soc Sci Med. 2010;71:13-17.
• Peek ME, Nunez-Smith M, Drum M, Lewis TT. Adapting the Everyday Discrimination Scale to medical settings: Reliability and validity testing in a sample of African-American patients. Ethn Dis. 2011;21(4):502-9.
• Peek ME, Lopez F, Williams HS et al. Development of a conceptual framework for understanding Shared Decision-Making among African-American LGBT patients and their clinicians. J Gen Intern Med. 2016;31(6):677-87.
• Tung EL, Johnson TA, O’Neal Y, Steenes AM, Caraballo G, Peek ME. Experiences of Community Violence Among Adults with Chronic Conditions: Qualitative Findings from Chicago. J Gen Intern Med. 2018;33(11): 1913-1920.
• Tung EL, Cagney K, Hawkley L, Peek ME. Social Isolation, Loneliness, and Violence Exposure in Urban Adults. Health Affairs. 2019;10;2670-2678.
• Peek ME, Vela MD, Chin MH. Practical lessons for teaching about race and racism: Successfully leading free, frank and fearless discussions. Acad Med. 2020;95:S139–S144.
• Peek ME, Simons R, Parker WF et al. Our Collective Obligation: An Action Plan for Mitigating COVID-19 Disparities. Am J Public Health.
• Persad G, Peek ME, Emanuel EJ. Fairly Prioritizing Groups for COVID-19 Vaccine Access. JAMA. 2020;324(16):1601-2.

In this episode, we are joined by Jaedon Avey, Health Program Analyst, and L’aakaw Eesh Kyle Wark, Researcher, both of whom are from the Southcentral Foundation in Anchorage Alaska, a non-profit, tribally owned and operated healthcare organization serving 65,000 Alaska Native/American Indian peoples in urban and rural communities across over 100,000 square miles of Southcentral Alaska. Emilia De Marchis talks with Jaedon and L’aakaw about screening for patient assets – not just risks – in healthcare settings.

To read the SIREN social screening report and a bevy of related resources, visit the SCREEN Report webpage.

Disclosure:

Dr. Avey and Mr. Wark were supported by Award #1CPIMP171148 from the U.S. Department of Health and Human Services’ Office of Minority Health. The contents of this podcast episode are the sole responsibility of the speakers and do not necessarily represent the official view of the Office of Minority Health. 

Resources noted in podcast: 

• Southcentral Foundation Research team: https://www.southcentralfoundation.com/services/research/  
• Wark K, Cheung K, Wolter E, Avey JP. "Engaging stakeholders in integrating social determinants of health into electronic health records: a scoping review". Int J Circumpolar Health. 2021 Dec;80(1):1943983.
• Ayed N, Toner S, Priebe S. Conceptualizing resilience in adult mental health literature: A systematic review and narrative synthesis. Psychol Psychother. 2019 Sep;92(3):299-341.
• Brave Heart MY, DeBruyn LM. The American Indian Holocaust: healing historical unresolved grief. Am Indian Alsk Nativ Ment Health Res (1987). 1998;8(2):56-78.
• Alaska Native Values for the Curriculum (uaf.edu)  
• Our Values – Cultural Center and Museum in Anchorage, Alaska (alaskanative.net)
• Traditional Values of Alaska poster (available for free from the publisher)
• Sharing Our Pathways Volume 11, Issue 1 (uaf.edu): “The cultural belief and traditional value systems that helped educate and mold generations of Alaska Natives years ago are just as valid and relevant today. The values listed - simple, genuine and insightful - illustrate the core beliefs of the diverse cultural groups that make up our great state. More than that, by collecting the traditional values of each tribe and presenting them in one place, we highlight the common ground and humanity that ties them together.”
• Connor-Davidson Resilience Scale
• Goins RT, Gregg JJ, Fiske A. Psychometric Properties of the Connor-Davidson Resilience Scale With Older American Indians: The Native Elder Care Study. Res Aging. 2013 Mar;35(2):123-143.

Elena Byhoff, MD, MSc, assistant professor in the Department of Medicine at Tufts Medical Center and Tufts University School of Medicine speaks with David Schleifer, PhD, the director of research at Public Agenda, a national, nonpartisan, nonprofit research and public engagement organization. This conversation is the third in a series focused on health care sector efforts to increase Awareness about both patient and community-level social conditions. Drs. Byhoff and Schleifer discuss their respective research studies examining patients’ and caregivers’ perspectives about the acceptability of social risk screening in the context of clinical care settings and explore the common question, “Should I screen for a social need I can’t address?”

Recommended references:

• De Marchis EH, Hessler D, Fichtenberg C, et al. Part I: A Quantitative Study of Social Risk Screening Acceptability in Patients and Caregivers. Am J Prev Med. 2019 Dec;57(6 Suppl 1):S25-S37.
• Byhoff E, De Marchis EH, Hessler D, et al. Part II: A Qualitative Study of Social Risk Screening Acceptability in Patients and Caregivers. Am J Prev Med. 2019 Dec;57(6 Suppl 1):S38-S46.
• Public Agenda. It’s About Trust: Low-Income Parents’ Perspectives on How Pediatricians Can Screen for Social Determinants of Health. 2019.

 This is the second of a two-part webinar series on implications of the Camden Coalition’s RCT results. 

In 2020, a major article on “healthcare hotspotting” may have caught your eye. The article described findings from our four-year, prospective, 800-person randomized evaluation of the Camden Core Model, an innovative and comprehensive approach to care coordination for patients with very high use of healthcare services. The study found no differences in hospital utilization between patients randomly assigned to the Camden Core Model and those who received usual care. In 2023, two secondary analyses were published looking at intervention dosage and engagement. Then teaming back up with MIT’s J-PAL to publish a new analysis, we looked at more intermediate measures of care coordination. These studies help to explain the original RCT’s primary outcomes findings. How do these findings align (or not) with the perspectives of complex care consumers and patient advocates? On May 9th we had a moderated panel with four National Consumer Scholars — advocates and activists with lived experience of complex health and social needs from across the country — as they shared their reactions to and reflections on the RCT findings. 

The panel included: 

-Pamela Corocan: Policy and regulatory advocate with AARP ME, Maine Women’s Lobby, and Maine Equal Justice 

-Nohora Gutierrez: Member of the RIDE (Research, Inclusion, Diversity, and Equity) Council, and the Next Steps Committee, activist with the National Multiple Sclerosis Society, and AARP advocate for improving the affordability and availability of specialty medicine for patients with chronic illnesses 

-Emily Cowen: Advocate with Kids as Self-advocates (KASA), Youth as Self-advocates (YASA), the Youth Steering Committee, the Caregiver Coalition, and People First of Connecticut 

- Carl Boyd: Community Liaison for the Center for Family Services, Parent Leader with New Jersey’s Early Childhood Comprehensive Systems Prenatal to Three (ECCS P-3) / Help Me Grow program, Co Chair for the Camden County Council for Young Children 

The webinar was moderated by Dawn Wiest, Director of Research and Evaluation at the Camden Coalition

Want to jump into the conversation? Join us at the Feb 2025 SIREN National Research Meeting: Advancing the Science of Social Care. Learn more at: https://sirenetwork.ucsf.edu/2025-national-research-meeting.

This season of the SIREN Podcast is supported by Kaiser Permanente. 

This episode features a conversation between two health center-based community organizers: Hilary Mar Lopez Nichols, from Oregon Health Sciences University Family Medicine Clinic at Richmond, and Toffer Lehnherr, from Partnership Health Center in Missoula, Montana. This is the first in a series of six Coffee & Science events on topics related to Alignment and Advocacy, which are the last two “A”s of the National Academy of Medicine’s framework that SIREN’s used to organize Coffee & Science. Alignment and Advocacy are both about what health care can do at the community level to address social needs.  In this conversation, Hilary and Toffer share their experiences with using community organizing in clinical settings to help advance health equity.

Recommended references:

• Morris JE. When “Patient-Centered” is Not Enough: A Call for Community-Centered Medicine. Ann Fam Med. 2019.
• Christens BD, Peterson NA, Speer PW. Community participation and psychological empowerment: Testing reciprocal causality using a cross-lagged panel design and latent constructs. Health Educ Behav. 2011.
• Wolf L, Vigna AJ, Inzeo PT et al.  From Roots to Results: A Qualitative Case Study of the Evolution of a Public Health Leadership Institute Building Capacity in Collaborating for Equity and Justice. Health Educ Behav. 2019.
• Speer PW, Tesdahl EA, Ayers JF : Community organizing practices in a globalizing era: Building power for health equity at the community level. J Health Psychol. 2013.
• Speer PW, Christens BD. A Kansas City case study: Local community organizing and change: Altering policy in the housing and community development system in Kansas City. J Community Applied Soc Psychol. 2011.
• Collins CR, Nealth JW, Neal ZO. An article that links (theoretically) community organizing with efficacy and empowerment: Transforming individual civic engagement into community collective efficacy: The role of bonding social capital. Am J Community Psychol. 2014.

This episode features a conversation between Tamara J. Cadet, PhD, LICSW, MPH, an Associate Professor at the Simmons School of Social Work and faculty at the Harvard School of Dental Medicine in Oral Health Policy and Epidemiology, and Bonnie Ewald, MA, the Associate Director of the Center for Health and Social Care Integration and Program Manager of Strategic Development and Policy for Rush University Medical Center’s Social Work and Community Health Department. This session is the sixth and final talk focused on health care sector efforts to provide patients with social service Assistance. In this conversation, Tammy and Bonnie dive into tele-social care practices, including ways these practices were affected by the COVID pandemic. Surfacing the perspectives of both patients and providers, they also explore the benefits and barriers to delivering social care by phone and video.

Recommended references:

• CHaSCI and the National Center for Complex Health and Social Needs. Tele-Social Care: Implications and Strategies. Feb 2021.
• CHaSCI and the National Center for Complex Health and Social Needs. Best practices and strategies for tele-social care (webinar recording).
• De Saxe Zerden L, Cadet TJ, Galambos C, Jones B. Social Work’s Commitment and Leadership to Address Social Determinants of Health and Integrate Social Care into Health Care. JHHSA. 2020.
• Kraus MW. Voice-Only Communication Enhances Empathic Accuracy. American Psychologist. 2017.
• DeGuzman PB, Jain N, Loureiro CG. Public Libraries as Partners in Telemedicine Delivery: A Review and Research Agenda. Public Library Quarterly. 2021.

This episode features a conversation between Bich Ha Pham, JD, the Director of Communications and Policy at the Healthcare Anchor Network, and Mike Koprowski, MA, Ed.M, who is the National Campaign Director at the National Low Income Housing Coalition. This is the fourth in a series of six Coffee & Science events on topics related to Alignment and Advocacy, which are the last two “A”s of the National Academy of Medicine’s framework that SIREN has used to organize Coffee & Science. Alignment and Advocacy are both about what health care can do at the community level to address social conditions. This conversation explores why and how health care organizations should engage in federal advocacy on issues like housing affordability. 

Recommended references:

• The Healthcare Anchor Network (website) 
• Healthcare Anchor Network. Principles for Health and Affordable Housing. 
• Current calls for action from the Opportunity Starts at Home campaign
• Pham BH, Zuckerman D, Fichtenberg C, Barnett K. Outside Their Comfort Zone: Health Sector Players Speaking Up for Housing Policy Change. Shelterforce. 2020.
• Counts NZ, Taylor LA, Willison CE, Galea S. Healthcare lobbying on upstream social determinants of health in the US. Prev Med. 2021.

This episode features a conversation between Kedar Mate, MD, President and CEO of the Institute for Healthcare Improvement and Saul Weiner, MD, Professor of Medicine, Pediatrics and Medical Education, Director of the Clinical Leaders and Academic Scholars Fellowship at the University of Illinois at Chicago, and Deputy Director of the Center of Innovation for Complex Chronic Health Care at the Veterans Health Administration. This session is the third of four talks focused on health care sector efforts to Adjust clinical care based on information about patients’ social circumstances. In this conversation, Kedar and Saul explore the intersection of social care adjustment and the practice of contextualizing care and raise questions about both potential benefits and unintended consequences of implementing contextualized care.

Recommended references:

•  https://www.contextualizingcare.org/ 
• Weiner SJ. Contextualizing care: An essential and measurable clinical competency. Patient Educ Couns. 2021. 
• Weiner SJ, Schwartz A, Altman L et al. Evaluation of a Patient-Collected Audio Audit and Feedback Quality Improvement Program on Clinician Attention to Patient Life Context and Health Care Costs in the Veterans Affairs Health Care System. JAMA Netw Open. 2020. 
• Weiner SJ, Schwartz A. Listening for What Matters: Avoiding Contextual Errors in Health Care. Oxford Univ Press. 2016.
• Weiner SJ. On Becoming a Healer: The Journey from Patient Care to Caring about Your Patients. Johns Hopkins Univ Press. 2020.
• Gawande A. “Personal Best”. The New Yorker. 2011.

Evidence is mounting about the impacts of interventions such as medically tailored meals and produce prescriptions on diet-related health conditions, fueling interest in these interventions among healthcare organizations and payers. On June 5th at 9am PT/12pm ET we heard experts discuss the latest research in this area. Panelists included researchers Drs. Kurt Hager (UMass), Hilary Seligman (UCSF), and Ariana Thompson-Lastad (UCSF) in discussion with Dr. Monica Soni, Chief Medical Officer of Covered California.

Want to jump into the conversation? Join us at the Feb 2025 SIREN National Research Meeting: Advancing the Science of Social Care. Learn more at: https://sirenetwork.ucsf.edu/2025-national-research-meeting.

This season of the SIREN Podcast is supported by Kaiser Permanente. 

This episode features a conversation between Danielle Hessler Jones, PhD, SIREN investigator and Professor in the Department of Family and Community Medicine at the University of California, San Francisco and Rachel Gold, PhD, MPH, an investigator at the Kaiser Permanente Northwest Center for Health Research and Lead Research Scientist at the OCHIN community health information network. This session is the first of four talks focused on health care sector efforts to Adjust clinical care based on information about patients’ social circumstances. In this conversation, Danielle and Rachel define Adjustment and explore research on the use of clinical decision support tools that might facilitate related interventions.

Recommended references:

• NASEM. Integrating Social Care into the Delivery of Health Care. 2019.
• Weiner S, Schwartz A. Listening for What Matters. 2016.
• Hessler D, Bowyer V, Gold R et al. Bringing Social Context into Diabetes Care: Intervening on Social Risks versus Providing Contextualized Care. Curr Diab Rep. 2019.
• Cottrell EK, Gold R, Likumahuwa S et al. Using Health Information Technology to Bring Social Determinants of Health into Primary Care: A Conceptual Framework to Guide Research. J Health Care Poor Underserved. 2018.
• Current projects mentioned in episode: COHERE; CRISP.

This episode features a conversation between Kelly Kelleher, a pediatrician and Vice President for Community Health and Community Health Services Research at Nationwide Children’s Hospital, and Reverend John Edgar, who is the Executive Director and Pastor Emeritus at United Methodist Church & Community Development for All People. This is the third in a series of six Coffee & Science events on topics related to Alignment and Advocacy, which are the last two “A”s of the National Academy of Medicine’s framework that SIREN has used to organize Coffee & Science. Alignment and Advocacy are both about what health care can do at the community level to address social conditions. This conversation explores how a children’s hospital and faith-based community development corporation have partnered to improve health and health equity in disadvantaged neighborhoods in Columbus, Ohio. 

Recommended references:

• Chisolm DJ, Jones C, Root ED, Dolce M, Kelleher KJ. A community development program and reduction in high-cost health care use. Pediatrics. 2020.
• Skinner D, Franz B, Kelleher K. How Should Health Care Organizations and Communities Work Together to Improve Neighborhood Conditions? AMA J Ethics. 2019.
• Kelleher K, Edgar J. Church and Hospital: Anchors Partnering to Achieve Community Transformation. Currents in Theology and Mission. 2019.
• Kelleher K, Reece J, Sandel M. The Healthy Neighborhood, Healthy Families Initiative. Pediatrics. 2018.
• Franz B et al. Hospital-Community Partnerships: Facilitating Communication for Population Health on Columbus' South Side. Health Commun. 2018.
• Axel-Lute M, Ortiz L. How a Risk-Averse Hospital and a Risk-Taking CDC Built a Functional Partnership. Shelterforce. 2017.
• Boyer KB, Chang DI. Case Study: Nationwide Children's Hospital: An Accountable Care Organization Going Upstream to Address Population Health. NAM Perspectives. 2017.

This episode features a conversation between Lauren Taylor, PhD, MDiv, MPH, a postdoctoral scholar at NYU School of Medicine, and Kelly Cronin, MPH, MS, Deputy Administrator, Innovation and Partnership at HHS Administration for Community Living. This session is the fifth in a series focused on health care sector efforts to provide Assistance to patients to reduce their social risks. In this conversation, Lauren and Kelly explore pressing questions surrounding the governance and interoperability of software platforms marketed to health care systems and designed to streamline information about and connection to community resources to address social needs. 

Recommended references:

• The Gravity Project. https://www.hl7.org/gravity/
• Stewards of Change. Project Unify homepage on the National Interoperability Collaborative Hub. https://hub.nic-us.org/groups/project-unify 
• San Diego Community Information Exchange Toolkit. https://ciesandiego.org/toolkit/ 
• Nichols & Taylor. Social Determinants as Public Goods: A New Approach to Financing Key Investments in Healthy Communities. 2018.
• Bradley & Taylor. The American Health Care Paradox. 2013.
• Cartier, Fichtenberg, & Gottlieb. Community Resource Referral Platforms: A Guide for Health Care Organizations. 2019.

Edited audience questions (clustered by theme): 

• Interoperability: What are the emerging interoperability standards across platforms? Will the work of The Gravity Project enable standards consistency that might support the CBOs? Are there any national certification efforts similar to ONC EHR certification process to propel interoperability standards between these new platforms?
• Data uses: How can we leverage data on the back end of these platforms to assess needs, improve care, and support advocacy?
• Effectiveness: Have we seen evidence on how effective the R&R systems are? How much should we invest in improving them? Would the $ being invested in these platforms be better spent on actual services rather than on an infrastructure to connect to services that are not robust enough? 
• Government role: Should the government’s position be to support CBO funding, capacity, and standards, not procurement of software? Are there anti-trust laws that would avoid a single company owning this entire space?
• Resident/community ownership: Are there ways for the community to benefit financially from these platforms, especially because they are providing the referral resources? What is the role of residents in this – after all, isn’t this all “for them?” 

In this episode, Andy Quiñones-Rivera, MD, MPH, an ER resident physician with LA county is joined by Loel Solomon, MPP, PhD, a Professor of Health Systems Science at the Kaiser Permanente School of Medicine and former Vice President for Community Health at Kaiser Permanente. The two explore the evolution of healthcare providers’ perspectives on social screening and what this means for the future of social care practice. Their discussion also begins re-imagining the roles and responsibilities of healthcare systems around social care activities like social screening.

To read the SIREN social screening report and a bevy of related resources, visit the SCREEN Report webpage.

Additional resources in this episode:

National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. Available online.

Listen to the SIREN Coffee & Science episode featuring Dr. Saul Weiner and Kedar Mate: https://sirenetwork.ucsf.edu/podcast/promise-and-pitfalls-adjusting-care-context