As our team reflected on what to include in SIREN's end-of-year newsletter, it will come as no surprise to those in our orbit that more than one topic popped to mind. We could mention the inspiring content you all brought to SIREN’s National Research Meeting in San Diego. We could highlight new reports of the economic impacts of the North Carolina Health Opportunities Pilots. We could share the new Ambulatory Specialty Model (included in the CMS CY2026 Physician Fee Schedule), which prioritizes identifying and addressing patients’ health-related social needs. Or we could (as always) mention the impressive slate of new evidence developed by you, the whole SIREN community, which we dearly hope will be used to inform practice and policy.

In parallel, we could describe the profound devaluation of science and learning, the gutting of federal government departments, the evisceration of the country's social safety-net, and the horrifying violations of human rights and dignity on our streets and around the world. The range of topics makes us enraged and engaged, frustrated and furious, disappointed and indignant, fearful and brave. 

English is famously inadequate at supporting us to simultaneously express more than one feeling. Instead of searching for new phrases to hide grants related to health equity, racism, disability, or social drivers of health or just banning words entirely (other distressing aspects of this year’s news) we thought it might be more fun to end the year with a different challenge. 

What words can you invent to capture the mixed emotions you have experienced over the past year? 

Send your ideas (and brief explanations) to us at SIREN@ucsf.edu by 12/31/25. 

Three winners will be sent authentic, limited edition SIREN caps. 

Awardees (and honorable mentions) will be recognized in SIREN's January newsletter and social media. 

For some inspiration, here are examples we have worked on (Full disclosure: some with support from ChatGPT, some not—you can guess later): 

“Mundoom”, which captures the unique sense of doing the mundane while feeling existential doom.

“Existential-okayness”, which combines a sense of the end of times and moderate stability. 

“Dreadstead”, which evokes safety at the ‘homestead' amid global anxiety.

We look forward to hearing your ideas!

Meanwhile, we wish you a restorative holiday season, filled with many kindnesses. 

–The SIREN Team

Registration Open for First SIREN Webinar of 2026!

Join us on February 12, 2026 for a conversation with SIREN co-directors Danielle Hessler Jones and Laura Gottlieb and Alameda Health System Medical Director of Patient Quality, Andy Quiñones-Rivera, about assessing patients’ experiences of healthcare-based social care. Here’s the scoop: Recent state and national efforts to incentivize social care have introduced measures focused on the quantity of social risk screening or referrals. These measures fail to simultaneously assess the quality of those services, including the patient experience of having healthcare teams ask about or intervene to address social conditions. The result has been an emerging national concern that rather than leading to care improvements, healthcare-based social care activities might instead be implemented in ways that cause harm to patients, e.g., by triggering stressful reactions, stigmatizing patients, not leading to meaningful service referrals, or otherwise undermining patients’ relationships with healthcare providers. In this conversation, panelists will describe their recent work developing and validating the new Patient Experience of Social Care (PESC) measure, which can serve to counter-balance the current quantity-focused assessments. 

Recording Now Available for SIREN Webinar: To screen or not to screen, that is (an important) question

On December 3, for our Shakespeare-inspired webinar, “To screen or not to screen, that is (an important) question” Drs. Jen Makelarski (UChicago) and Danielle Cullen (Children’s Hospital of Philadelphia) shared their recent research on universal intervention models in pediatrics settings. The presentations were followed by a moderated discussion, with SIREN co-Director Dr. Laura Gottlieb, the presenters, and Dr. Sarah DeSilvey from the Gravity Project.

Meetings & Conferences

RISE: The RISE Healthy Communities Summit – March 23-25, 2026 | Orlando, FL

AcademyHealth: 2026 Annual Research Meeting – May 30-June 2, 2026 | Seattle, WA | Abstracts due January 6, 2026 at 2pm PT 

Camden Coalition: Putting Care at the Center 2026 – October 14-16, 2026 | Oakland, CA 

NAPCRG: 54th Annual Meeting – November 24-26, 2025 | Toronto, Canada

SIREN: To Screen or Not to Screen, That is (An Important) Question – December 3, 2025

Systems for Action: Integrating Health and Social Services through a Novel Independent Practice Association – Originally broadcast December 10, 2025 

HealthBegins: Rest, Resistance, and Hope: Reflections on 2025 – Originally broadcast December 11, 2025 

Below we share multiple SIREN-relevant articles published since the last newsletter. For a full list, see the SIREN Evidence and Resource Library. As always, if you are aware of resources that you think should be added to the library, please send them our way.

Peer-Reviewed Articles

Awareness / Screening

Impact of Centers for Medicare & Medicaid Services Screening Mandate on Inpatient Z-Code Documentation of Social Drivers of Health Santiago C, Steele N, Lee J, et al. | Journal of General Internal Medicine
Key results: “The CMS SDOH mandate likely led to a modest growth in claims-based documentation of social risks.”

Adverse Childhood Experiences (ACEs) Screening in Pediatric Primary Care: Is "Social Drivers of Health (SDoH) Screening" Sufficient? Zielinski S, Valdez J, James J, et al. | International Journal of Environmental Research and Public Health
Key results: “52% of individuals who reported a positive ACE screen were not flagged by SDOH screening.”

Beyond the Check Box: Development of the Nutrition Health Related Social Need Assessment and Referral Tool (N-HART) Rising KL, Kemp M, Gerolamo A, et al. | Journal of General Internal Medicine
“The N-HART is a novel 13-item tool that screens for food and nutrition needs and recommends a best fit food resource type based on an individual's needs.”

Prevalence of Health-Related Social Needs: Inpatient Versus Ambulatory Pediatric Populations Muleta H, Levano S, Gabbay JM, et al. | Journal of Pediatrics
Key results: In a tertiary children’s hospital in Bronx, NY, the prevalence of unmet HRSNs was more than twice as high among hospitalized patients than among ambulatory patients (28% vs 13%).

Documentation of Adverse Social Drivers of Health in US Emergency Departments Molina MF, Cash RE, Espinola JA, Boggs KM, Camargo CA Jr, Samuels-Kalow ME | Journal of the American College of Emergency Physicians
Key results: 94% of EDs that screened for at least 1 risk factor had policies requiring documentation of screening. 24/7 social work availability was associated with greater odds of having at least 1 SDOH documentation policy. 

Homeless Services Data vs Health Records to Recognize Homelessness Pita MA, McDowell CH, Ma P, et al. | JAMA Health Forum
Key results: “Homelessness was potentially missed in 64% of ED visits and 39% of admissions.”

Assistance

Sub-Population Differences in Connecting to Resources to Address Social Needs Gurewich DA, Friedman H, Li M, et al. | American Journal of Preventive Medicine
Key results: Social worker navigation was more effective than a listing of generic VA resources for two groups of veterans: low income veterans who are ineligible for VA disability benefits and veterans with high comorbidities.

Language and Demographic Disparities in Social Needs and Referral Preferences in the Pediatric ED Tedford NJ, Mujahed T, Taylor IK, et al. | Academic Pediatrics 
Key results: Prevalence of unmet needs was highest among Spanish-speaking caregivers. Spanish language preference, public or no insurance, Hispanic ethnicity, and non-White racial backgrounds was each associated with greater interest in referral.

Food interventions

Medically Tailored Meals: A Case for Federal Policy Action Macpherson C, Frist WH, Gillen E | Healthcare
Key results: This systematic review finds that MTMs improve health outcomes, reduce hospitalizations, and lower total cost of care, and recommends several approaches to increasing availability and utilization. 

Perceived Benefit and Impact of a Health Care-Based Food Pantry: "One Stop Shop" Plencner LM, Kelty K, Demaestri S, et al. | Journal of Ambulatory Care Management 
Key results: In qualitative interviews, all 23 users of the pantry reported positive impacts on household budget but limited impacts on diet and health.

Competitors Unite: A Cross-Health System Collaboration to Address Community Food Insecurity Brown R, Salazar K, Choi S, et al. | Journal of Health Care for the Poor and Underserved
Key conclusion: “Intentionally eliminating boundaries and identifying common goals between competitor health systems can create opportunities for shared learning and accelerate dissemination of evidence-based practices.”

Food Assistance Experiences of Food-Insecure Community Members in Baton Rouge, Louisiana: A Qualitative Study Dunaway C, Edomwande C, Myers CA, Apolzan JW, Davis G, Ardoin TW | Journal of Hunger and Environmental Nutrition 
Key results: Participants noted the administrative complexity of SNAP and lack of awareness of other food resources as limiting their participation and mentioned strategies they used when food benefits were insufficient to meet their needs.

Medicaid policy

When State Medicaid Demonstrations End: Projected Eligibility Loss After a MassHealth Housing Support Program Transition McCann NC, Hsu HE, Ettinger de Cuba S, et al. | Health Affairs Scholar
Key results: “Among individuals enrolled (in the MassHealth Housing Support Program) from 2021 to 2024, 68% would no longer qualify under updated 2025 criteria.” 

Implementation research and resources

What Do I Do When They Disclose? Responding to Intimate Partner Violence and Coercive Control in Primary Care Neil J, Giles F, Hegarty K | Australian Journal of General Practice
This paper provides guidance and a flowchart for how to respond to IPV disclosures in primary care using the World Health Organization ‘LIVES’ framework (Listen, Inquire about needs, Validate, Enhance safety and offer Support).

Expanding Implementation of a Social Determinants of Health Screening and Referral Program to Community-Based Pediatric Clinics Gibson A, Mathur M, Cavenaugh S, et al. | Academic Pediatrics

Optimizing the Collection, Integration, and Use of Health-Related Social Needs Data in the Primary Care Setting: Recommendations Derived from Key Interest-Holders LeBeau K, Bergner EM, Harris JW, et al. | Journal of Primary Care & Community Health

Examining the Social Prescription Process: Barriers, Facilitators, and the Role of Health Information Technology Haynes D, Wedlow M, Gilliam K, Pratt R, Beebe TJ | Social Science & Medicine

Patient Perspectives on Loneliness Interventions in Primary Care: A Qualitative Study Saulnier KG, Lapidos A, Jagusch J, Garland S, Harrod M, Pfeiffer PN | Psychological Services

Commentaries and Blogs

Medicaid’s Essential Investments to Address Health-Related Social Needs Pollack H | Milbank Quarterly

The Future of North Carolina’s Healthy Opportunities Pilots and What it Means for Other Medicaid Programs Considering Social Needs Programs Kenen J | Milbank Memorial Fund

From Policy to One's Plate: Washington's New Obsession with "Food Is Medicine" Davitian L | The Senior Care Pharmacist

What’s Keeping the U.S. From Better Population Health? Berkowitz S | Diabetes Care