First off, we are excited to kick off the New Year by announcing winners of the word-smithing competition we announced in our December newsletter. As a reminder, we asked folks to share invented words that capture the past year’s wild mix of emotions. And sheesh, we had loads of fun sifting through your brilliant responses! All winners listed below will receive their SIREN caps in the mail.

Our first prize goes to Ellen Schultz for the word myopicoping, which she defined as "Staying resolutely focused on the mundane right in front of you while avoiding eye contact with the Dread Beast lurking in the blurry distance. You know he’s there, you can smell his foul odor that reeks of social rot and authoritarianism, but if you don’t look up and just keep humming, you may just get through one more day without having to look him in the eye.” She added “Use it in a sentence, you say? Myopicoping is a popular strategy for reaching a state of Okay-NotOkay even in the midst of social chaos.”

Runner-up entries were awarded to: 

Elena Broaddus for the expression Moral haphazard, which she described as "Like 'moral hazard' but more chaotic. Being simultaneously insulated from and horrified by 2025's dumpster fire of injustice."

Kim Reno for the word fractocalypse, "a catastrophic unraveling where systems, expectations, and stability fracture all at once, leaving chaos as the only constant."

And last but not least to the venerable Janice Tufte for the entry dreadnod. It defies definition.

Grateful to you all for playing along. We wish everyone fortitude in the year to come. 

–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. 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 existing quantity-focused assessments. 

Join SIREN at Camden Coalition's Putting Care at the Center 2026 Conference

SIREN is a planning partner for the research and evaluation track at this year’s Putting Care at the Center 2026 – being held on October 14-16, 2026 in Oakland CA. Please consider submitting workshop proposals on social interventions evaluation topics relevant for complex care populations. Workshops are due March 4th, 2026. For more information click here.

CMS is Seeking Information About Well-Being and Nutrition Programs for Medicare Advantage Members

CMS included a request for information (RFI) in the latest Medicare Advantage (MA) proposed rule, seeking information about “tools and policies that improve overall health, happiness, and satisfaction in life that could include aspects of emotional well-being, social connections, purpose, and fulfillment” and “tools and policies that achieve optimal nutrition and improve preventive care in MA .” This is a great opportunity to submit comments about social isolation and food insecurity interventions in older adults. Submit your comments here by Monday 1/26, 5pm ET.

Webinars

Systems for Action: ACCESS: Aligning Community Care through Embedded School-Based Systems – January 28, 2026 | 9am PT / 12pm ET

Systems for Action: Participatory Budgeting for Health Equity: A Unified, Multisectoral Approach – February 4, 2026 | 9am PT / 12pm ET

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

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 friends—this month we reintroduced summaries for the Research Round-Up entries. After you review the library entries this month, let us know if the summaries are helpful for you by clicking 👍 or 👎 below. We’ll appreciate your feedback! 

Peer-Reviewed Articles

Awareness / Screening Studies 

Performance of 2-Stage Health-Related Social Needs Screening Using Area-Level Measure Vest JR, Harle CA, Blackburn J | American Journal of Managed Care

Although a 2-stage approach based on area-level socioeconomic measures can reduce the number of patients requiring individual-level HRSN screening, large percentages of patients in need would be missed.

Comparison of the Performance of Three Health Related Social Needs Screening Tools Fennelly KM, Calvo-Friedman A, Clapp J, et al. | Journal of the American Board of Family Medicine

Despite differences in question phrasing and response options, all 3 screeners (a tool developed by NYC Health + Hospitals, a version of the AHC tool, and WellRx) performed similarly.

Validation of an Electronic Health Record Algorithm for Identifying Housing-Related Needs in a Safety-Net Health System McCann NC, de Cuba SE, Hofman M, et al. | Health Services Research

HRSN screening yielded the highest single-element sensitivity but missed 40% of those with verified housing-related needs. An algorithm leveraging structured data elements tailored to local context had moderate sensitivity and high specificity, identifying more housing-related needs than diagnostic codes alone.

Merging Law and Medicine: Patient Attitudes About and Experiences with Social Needs Screening and Medical-Legal Partnerships in Primary Care Graham JD, Kraschnewski JL, Allen SI, Makhlouf M, Llavona-Ortiz J, Calo WA | Journal of Primary Care & Community Health

This paper reports on the social needs screening experiences/preferences and interest in MLPs among a nationally representative sample of 500 U.S. adults who had visited a primary care provider in the past year.

Health Care Providers' Perceptions of Unmet Needs Among African American Cancer Caregivers: Qualitative Investigation Among US Medical Professionals Love B, Dermid G, Upshaw S, Stark A | JMIR Cancer

Providers identified three types of unmet needs among African American cancer caregivers: practical needs, social-emotional needs, and cultural barriers and made recommendations such as:  (1) formal acknowledgment and compensation of caregiving as essential work; (2) integration of caregivers as equal members of multidisciplinary care teams; (3) recognition and leveraging of cultural assets, including strong family networks, community values, and faith-based support. 

The First Step Is Knowing: Quantifying Social Need Through Screening in a Pediatric Surgery Clinic Rollins PD, King S, Majcher A, Hughes BD, Newman EA, Perone EE | Journal of Surgical Research

One in five pediatric surgery clinic outpatients (241 of 1410, 17.1%) screened positive for at least one unmet social need. The authors conclude that pediatric surgery patients experience high rates of unmet social need and that standardized screening is feasible in an ambulatory surgical care setting. 

Socioeconomic and Psychosocial Needs in Pediatric Infectious Diseases Outpatient Settings Day ME, Choony C, Duan Q, et al. | Clinical Pediatrics

Caregivers reported anxiety (70%), depression (20%), and food insecurity (10%), with 20% reporting ≥4 ACEs. Median Social Deprivation Index (SDI) scores were twice as high for children with reported food insecurity (0.61) compared to those without food insecurity (0.61 vs 0.28, P < .001).

Characterizing Intersecting Social Determinants of Health During Pregnancy: A Descriptive Cross-Sectional Analysis from a Northern New England Health System Dev A, Allen SE, Cass I, Canavan CR, Velmineti V, Goodman DJ | Frontiers in Medicine

Social isolation emerged as a significant concern for non-urban pregnant women who had no other reported social determinants.

Help-Seeking Patterns Among Socially Isolated Patients in Primary Care Patel MR, Leung CW, Saksena R, Hao W | J Gen Intern Med

Healthcare systems should implement proactive strategies to capture patients with social isolation but no material hardships needs since existing screening and referral approaches may overlook patients who appear demographically advantaged.

Assistance
Effectiveness Studies

Health-Related Social Needs and Health Care Utilization in the Accountable Health Communities Model Sidebottom AC, Martins S, Vacquier MC, Dechaine C, Behrens D | JAMA Network Open

Resolution of individual HRSNs was not associated with subsequent reductions in inpatient admission or ED visits. Resolution of food needs was associated with a small increase in inpatient admissions. This is the first study that we know of that directly examines the association between needs resolution and health care utilization in the AHC model. See accompanying commentary here

The Veggie Vouchers Intervention to Promote SNAP Fruit and Vegetable Incentive Program Use for Families with Food Insecurity: A Single-Arm Feasibility Study Adams EL, Savidge M, Reesor-Oyer L, et al. | Pilot and Feasibility Studies

After brief education about the program by pediatricians, 70% of caregivers used a free trial. At the end of the free trial, only 20% used the SNAP F&V incentive (50% or more discount on fruits and vegetables).

Implementation and Outcomes of a Pharmacist-Led Social Determinants of Health Screening and Intervention Program in an Integrated Health System Specialty Pharmacy Model Lakada I, Stutsky M, Huynh C, Periyasamy S, Idusuyi A | Journal of the American Pharmacists Association

This small pilot study found that a pharmacist-led SDOH program had high acceptance rate (80%) and patients reported relatively high perceived benefit (63%). Patients receiving interventions demonstrated clinical outcomes improvements, including a mean RAPID3 score reduction of 3 points (range: 1.3-27.3) and mean LDL reduction of 29.75 mg/dL (range: 44-137) for RA and hyperlipidemia. 

Five-Year Outcomes of a CHW-Driven Maternal-Infant Health Model through a County Health Department in a Medically Underserved Region Gonzalvo JD, Chaudhry F, Burney HN, et al. | Journal of Health Care for the Poor and Underserved

This Medicaid-covered, CHW-driven Pre to 3 Program provided free, hands-on support for infants, parents, and families from the first trimester of pregnancy until the child's third birthday and improved breastfeeding initiation, safe sleep practices, adequate prenatal care, child vaccination rates, food security, housing stability, and employment status.

Improving Vaccination Rates by Connecting Families to Community Resources Arthur J, Terhaar AS, Huang J, LaBarge G, Barnidge E | Clinical pediatrics

A social needs screening and navigation intervention in a Midwestern, low-income, pediatric clinic improved immunization adherence in intervention compared to control group participants.

Connected Care for Older Adults: A Pilot Intervention Engaging Community Health Workers to Advance Age-Friendly Care in Rural Oregon De Lima B, Miller L, Foster E, Ready J, Eckstrom E | Journal of the American Geriatrics Society

Embedding community health workers (CHWs) into rural primary care teams to assist with implementation of the 4Ms of the Age-Friendly Health System made a positive difference for 95% of responding patients (n = 120), and 100% of responding providers (n = 19) were "very satisfied" with the program. Early data suggest this program also may reduce health care utilization. Clinicians cited the CHWs' ability to support resource connections, address social isolation and social needs, provide regular check-ins, and help to get patients and families engaged in care as positive components of the model. 

Implementation Studies

An Introduction to North Carolina Integrated Care for Kids (NC InCK): A Model to Support Whole-Child Health Wong CA, Allin S, Swanson C, et al. | Healthcare

This study describes the design of the North Carolina Integrated Care for Kids (NC InCK) model. A model collaboratively developed by healthcare systems, the state Medicaid agency, managed care organizations, child-serving organizations, and families. It integrates care using three key approaches: Risk Stratification Algorithm, Family-Centered Care Management and Alternative Payment Model. 

Food Insecurity Screening and Intervention Strategies in Pediatric Primary Care Practices: A Mixed Methods Study Suarez L, James G, Montez K, et al. | Academic Pediatrics

This study describes and identifies barriers and facilitators to FI screening, intervention, and documentation processes in 27 clinics across the nation.

From Mandate to Meaning: A Health Equity Implementation Framework and Knowledge-to-Action-Informed Qualitative Study of Health-Related Social Needs Implementation Zimmer RP, Singletary C, Aguilar A, et al. | Health Services Insights

Frontline staff (including clinicians, navigators, and CHWs) reported disjointed workflows, unclear referral roles, and limited communication related to HRSN implementation. Suggested improvement strategies included role-specific training, participatory design, improved integration of CHWs into care teams, feedback loops, and locally adapted referral protocols. 

Navigating the Journey from Hospital to Help: Family Perspectives on Overcoming Barriers to Connecting with Resources to Address Social Needs Kovaric K, Pham Q, Earp A, Wellman N | Hospital Pediatrics

Barriers experienced by 25 caregivers of hospitalized children included feeling overwhelmed, slow resource access, poor communication, and referrals and resources that do not match families' needs. Families desired continued support after hospital discharge to overcome barriers to resource connection, particularly for Spanish-speaking caregivers.

Evaluation Strategies

Evolving Food as Medicine Programs to Advance Health Equity: Insights from Two Decades of Practice Thomas O, Gago CM, Egan KA, Sheward R, Burt KG | Current Opinion in Pediatrics

This case study describes equity-centered evaluation strategies used by a food as medicine initiative Nourishing Our Community Program (NoC)at Boston Medical Center (BMC). Also, it provides a replicable framework for health systems.

Commentaries & Blogs

Integration of Food and Nutrition into Oncology Care: Proceedings of the Food is Medicine in Oncology Care Symposium Raza S, Garfield KM, Sullivan KR, et al. | Cancer

Summary of the first oncology-specific FIM symposium, which occurred December 2024. 

Let us know if the summaries are helpful for you by clicking 👍 or 👎 below.