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SIREN Coffee & Science
27 minutes | Jun 28, 2021
Delivering Social Care in the Virtual Frontier
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.
26 minutes | Jun 15, 2021
Should Community Resource Referral Platforms be a Public Good?
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?”
24 minutes | Jun 2, 2021
Evaluation of the Accountable Health Communities Model
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.
26 minutes | May 17, 2021
Global Lessons on Addressing Social Isolation and Loneliness
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
29 minutes | May 3, 2021
Challenging Racist Systems, Processes, and Analyses in Social Care
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.
16 minutes | Apr 19, 2021
Community Health Workers and Social Care Integration
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.
28 minutes | Apr 13, 2021
Bonus Episode: Awareness Afterparty
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.
27 minutes | Mar 30, 2021
Social Risks vs. Social Needs: Assessing Patients' Interest in Assistance
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.
24 minutes | Mar 15, 2021
Building Accountability for Social Risk Screening into State Medicaid Programs
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.
26 minutes | Mar 3, 2021
Understanding Patients’ Perspectives on Social Risk Screening
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.
28 minutes | Feb 16, 2021
The Intersection of Racism, Discrimination, and Social Risk Screening in Clinical Settings
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.
25 minutes | Feb 1, 2021
To Scale or Not to Scale: Social Risk Screening and the US Health Care System
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.
34 minutes | Dec 21, 2020
Introducing the SIREN Coffee & Science Series: The NASEM Social Care Framework
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.
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