The SIREN Podcast

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Community Health Workers and Social Care Integration Apr 19, 2021

Show notes

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.

Bonus Episode: Awareness Afterparty Apr 12, 2021

Show notes

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.

Social Risks vs. Social Needs: Assessing Patients' Interest in Assistance Mar 29, 2021

Show notes

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.

Building Accountability for Social Risk Screening into State Medicaid Programs Mar 15, 2021

Show notes

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.

Understanding Patients’ Perspectives on Social Risk Screening Mar 03, 2021

Show notes

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.

The Intersection of Racism, Discrimination, and Social Risk Screening in Clinical Settings Feb 16, 2021

Show notes

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.

To Scale or Not to Scale: Social Risk Screening and the US Health Care System Feb 01, 2021

Show notes

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.

Introducing the SIREN Coffee & Science Series: The NASEM Social Care Framework Dec 21, 2020

Show notes

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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