The SIREN Podcast – Details, episodes & analysis

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 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. 

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 

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 

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.

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 

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 

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

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.

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.