SIREN Friends,

Since we launched SIREN’s monthly newsletter, our team has approached each End of Year (EOY) edition with a combination of enthusiasm and trepidation. The enthusiasm is a no-brainer: it’s easy to be enthusiastic about learning alongside all of you. The trepidation stems from the scary task of synthesizing the year’s literature in a few paragraphs. (Maybe it’s a don’t-try-this-at-home kind of activity, but if you DO want to try, please send us your 2025 version before 12/10/2025!) The synthesis business is made all the more challenging this year by the 541 (a record!) new entries in the SIREN ERL. Hats off to our readers—those pieces reflect the thoughtful work of many of you, including frontline healthcare workers, policymakers, social care researchers, and funders.

Of course we can’t describe it all. But below, curated to whet your winter social care appetites, we describe a handful of the many things we read and/or listened to in 2024 that we think should not be overlooked.

It was not lost on us that several federal policies attempting to universalize social care practices are now truly in motion. Of course you all are aware that some of the prior social drivers reporting recommendations transitioned to being reporting requirements (e.g., from select CMS programs.) This year, the CMS Physician Fee Schedule final rule also added codes to enable Medicare billing both for social risk screening as part of an annual wellness visit and for auxiliary staff (like CHWs) in some circumstances. On a social care bender, CMS has gone on to signal it may add interventions to its hospital inpatient quality reporting requirements, which will strengthen alignment with NCQA’s social drivers work. And it sure looks like NCQA is considering expanding their social drivers requirements by adding HEDIS measures related to utilities security and social isolation.

What’s the research that undergirds all this policy momentum? (Or is it the policies that are propelling the research? We forget.) You shouldn’t walk away from 2024 without being aware of two riveting reports (yes, riveting.) The first is the interim evaluation from the North Carolina Healthy Opportunities Pilots (NC HOP), which describes findings from “the nation’s first comprehensive program to test and evaluate the impact of providing select evidence-based, non-medical interventions related to housing, food, transportation and interpersonal safety and toxic stress to high-needs Medicaid enrollees.” Over five years, North Carolina provided $650 million in Medicaid funding to those pilots. The interim evaluation published in April reported that HOP participation was associated with reduction in participants’ social needs, decreased emergency department utilization, and lower total costs of care; though it also showed significant decreases in inpatient and outpatient visits among pilot participants, evaluators were unable to attribute those changes to HOP participation.

The second unmissable research emerging this year is the CMS Center for Medicare and Medicaid Innovation’s Accountable Health Communities (AHC) 3rd report. For those of you who live under a rock (tempting, we know) AHC was the Innovation Center’s 5-year model testing “whether systematically identifying and addressing the health-related social needs of community-dwelling Medicare and Medicaid beneficiaries impacts total health care costs and utilization.” We wouldn’t dare spoil the 165-page report for you…but if you really want us to, check out the tables below about cost/utilization findings from the report’s highlights. Though it’s hard to understand why many utilization findings differed by Medicaid/Medicare status, across the two programs, the evaluation found significantly different reductions in total expenditures in intervention vs non-intervention arms of the randomized intervention (referred to as ‘Assistance Track’ in Table below). Our interest was piqued by a couple of other findings that you can chew on with us: significant outcomes seemed driven by patients with diabetes, chronic pulmonary disease, and major depressive disorder; and there were larger utilization impacts in patients identifying as non-White and/or Hispanic. (Don’t worry—there are more pearls in the report for you to find on your own.)

Exhibit ES-2. Assistance Track Impacts on Expenditures and Hospital Use

Citation: RTI International. Accountable Health Communities (AHC) Model Evaluation: Third Evaluation Report. November 2024. Available online.

Exhibit ES-3. Alignment Track Impacts on Hospital Use

Citation: RTI International. Accountable Health Communities (AHC) Model Evaluation: Third Evaluation Report. November 2024. Available online.

And now, to close out 2024, we’ll throw in some shameless self-promotion (self-promotion, for sure; shameless is up to us, I guess). There are two SIREN products/events that we would hate for you to miss. And they really seem like they would be of interest since you, remarkably dedicated social care reader, have read almost this whole letter!

First, we are handing you the Jan 2024 Milbank Quarterly paper Revising the Logic Model Behind Health Care’s Social Care Investments, which stems from our team’s observations over time that the research on social care is telling us there are multiple pathways connecting social risk screening to health. If you prefer listening, you can find our team’s webinar presenting the conceptual model here.

Second, it really would be silly if we didn’t use our EOY newsletter to slip in one last reminder about SIREN’s 3rd National Research Meeting, which will be held in San Diego, February 2-4, 2025. We are anticipating that both the invited plenaries and phenomenal array of oral and poster research presentations on the agenda will spark exciting discussions between old and new friends. To our shock and delight, registration is now sold out, but we welcome you to join the waitlist.

For now, we are wishing you a restful and joyful holiday season. We will have a lot to do together in the coming years.

The SIREN Team

Webinars

January Medicaid Learning Opportunities

Register now for a series of January webinars exploring the many different ways state Medicaid programs are investing in addressing social needs—both for individuals (ICF and Center for Health Care Strategies(CHCS) events) and communities (SIREN event). Webinar descriptions and links to register for these three webinars are included below.

ICF: Medicare and Medicaid Move Upstream to Address Social Determinants of Health – January 7, 2025 | 9am PT/12pm ET

Center for Health Care Strategies: Medicaid Nutrition Supports: Implementation Innovations – January 9, 2025 | 10am PT/1pm ET

SIREN and the Center for Health Law & Policy Innovation of Harvard Law School: State Medicaid Program Requirements for Community Reinvestment: Will They Improve Health? – January 14, 2025 | 12pm PT/3pm ET

Meetings & Conferences

2025 SIREN National Research Meeting: Advancing the Science of Social Care – February 2-4, 2025 | San Diego, CA

NCEAS 2025 Annual Conference: Healthcare Delivery Steps Up to Social Care: Implications for Health Professions Education – February 24-25, 2025 | virtual

Centers for Medicare & Medicaid Services: CMS Health Equity Conference – April 23-24, 2025 | Bethesda, MD & virtual

American Hospital Association: Accelerating Health Equity Conference – May 19-22, 2025 | Baltimore, MD | Early bird registration ends March 31, 2025.

AcademyHealth 2025 Annual Research Meeting – June 7-10, 2025 |  Minneapolis, MN | Abstracts due January 8, 2025.

We share some articles published since the last newsletter, handpicked for you. 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 

Using Z Codes to Document Social Risk Factors in the Electronic Health Record: A Scoping Review Baker KM, Hill MA, Goldberg DG, et al. | Medical Care

Physician Documentation of Social Determinants of Health: Results from Two National Surveys Iott BE, Patel V, Richwine C | Journal of General Internal Medicine

Health-Related Social Needs Screening, Reporting, and Assistance in a Large Health System Llamocca EN, Bossick AS, Perkins DW, et al. | Preventive Medicine

Pilot Implementation and Qualitative Evaluation of a Financial Hardship Screening Among Native American Patients with Cancer Janitz AE, Anderson-Buettner AS, Madison SD, et al. | Supportive Care in Cancer

Charting New Territory: The Early Lessons in Integrating Social Determinant of Health (SDOH) Measures into Practice Nava A, Bishop K, Lissin P, Harrington RL | Health Affairs Scholar

Assistance

The Social Risk ACTIONS Framework: Characterizing Responses to Social Risks by Health Care Delivery Organizations Rao M, Maciejewski ML, Nelson K, et al. | Population Health Management

Addressing Social and Health Needs in Health Care: Characterizing Case Managers' Work to Address Patient-Defined Goals Brewster AL, Hernandez E, Knox M, Rubio K, Sachdeva I | Health Services Research

Design and Framework of a Technology-Based Closed-Loop Referral Project for Care Coordination of Social Determinants of Health Sharma SV, McPherson H, Sandoval M, et al. | Population Health Management

Impact of an Inpatient Social Needs Screening Program: Did Our Referral Resolve Your Need? Lax Y, Pacheco A, Yost E, et al. | Hospital Pediatrics

The Rise of Pediatric Inpatient Social Needs Screening and Referral Systems Leary JC, Landrigan CP, Garg A | Academic Pediatrics

Emergency Department Food Insecurity Screening, Food Voucher Distribution and Utilization: A Prospective Cohort Study Ulintz AJ, Patel SS, Anderson K, et al. | Western Journal of Emergency Medicine

Evaluation of an Indigenous Produce Box Program: Food Access and Nutrition in an Urban American Indian/Alaska Native Community Keshen R, Riggs C, Vaidya N, et al. | Journal of Health Care for the Poor and Underserved

Caregiver Perspectives on Pediatric Primary Care Clinic-Based Food and Nutrition Assistance Programs Vasan A, Negro D, Yazdani M, et al. | Journal of Health Care for the Poor and Underserved

Hospitalized and Hungry: A Mixed Methods Study Assessing Immigrant Caregiver Perspectives on an Inpatient Food Insecurity Intervention Masciale M, Asaithambi R, Gibbs KD, et al. | Journal of Health Care for the Poor and Underserved

Hunger in the Hospital: Assessing Inpatient Caregiver Food Insecurity and a Program to Address It Schmitt M, Bejar AR, Trieu E, Farnan S, Williams NF, Bruce J | Journal of Health Care for the Poor and Underserved

Commentaries & Blogs

Cross-Sector Support for a Policy Framework to Tackle Social Determinants of Health Butler SM | JAMA Health Forum

Prioritizing Research on Social Determinants of Health-"Yes, and…" Zenk SN, Simoni JM, Pérez-Stable EJ | JAMA Internal Medicine

Tools and Toolkits

Social Needs Investment Lab | Elevance Health and HealthBegins