The SIREN Podcast

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.

This is the first 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. It did ours! The article described findings from a four-year, prospective, 800-person randomized evaluation of the Camden Coalition’s 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, the Camden Coalition published two secondary analyses looking at intervention dosage and engagement, and they teamed back up with MIT’s J-PAL to publish a new analysis looking at more intermediate measures of care coordination. These studies help to explain the original RCT’s primary outcomes findings. On April 5, 9-10am PT, participants joined us for a moderated panel discussion with Kathleen Noonan (Camden Coalition), Kedar Mate (Institute for Healthcare Improvement), and Damon Francis (Alameda Health System) about study implications. Prior to the panel conversation, Amy Finkelstein (MIT) and Aaron Truchil (Camden Coalition) briefly presented study findings. 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.

On March 29, 2024, the Harvard Medical School Center for Bioethics convened a session of the Organizational Ethics Consortia Series on social care. Addressing health inequity generally requires attention to the most marginalized patients, whose health is often undermined by social, legal and financial challenges. In response, many health care delivery organizations have begun to collect data about health-related social needs and build organizational capacity to address these needs, either “in-house” or through partnerships with community-based organizations. This gives rise to challenging ethical questions: Presenters: Monica E. Peek, MD, MPH, MSc, Ellen H. Block Professor of Health Justice, Section of General Internal Medicine; Associate Vice-Chair for Research Faculty Development, Dept of Medicine; Associate Director, Chicago Center for Diabetes Translation Research; Dir. of Research (Assoc. Director), MacLean Center for Clinical Medical Ethics; Executive Medical Director, Community Health Innovation Marshall Chin, MD, MPH, Richard Parrillo Family Distinguished Service Professor of Healthcare Ethics in the Department of Medicine, University of Chicago; Associate Director, MacLean Center for Clinical Medical Ethics; Co-Director, Robert Wood Johnson Foundation Advancing Health Equity: Leading Care, Payment, and Systems Transformation National Program Office; Co-Chair, CMS Health Care Payment Learning and Action Network Health Equity Advisory Team Laura Gottlieb, MD, MPH, Co-director, Social Interventions Research and Evaluation Network (SIREN); Professor, Department of Family and Community Medicine, University of California, San Francisco Moderator: Lauren A Taylor, PhD, MDiv, Assistant Professor, NYU Grossman School of Medicine Consortium Co-Chair: Charlotte H. Harrison, PhD, JD, MPH, HEC-C, Co-Chair, Organizational Ethics Consortium, Harvard Medical School Center for Bioethics; Immediate Past Hospital Ethicist and Director, Office of Ethics, Boston Children’s Hospital This consortia series provides a forum for local, national, and international discussion of organizational-level ethical issues and processes to address them, with the aim of cultivating a learning community of practitioners and scholars in this evolving field. We are grateful to the Harvard Medical School Center for Bioethics for making this recording available to the SIREN Podcast audience. To learn more, visit https://bioethics.hms.harvard.edu/

On Monday March 11th participants joined us for a conversation about the new SIREN Social Care Conceptual Model! Emerging evidence suggests that social care programs do not affect health solely by connecting patients with social services and reducing socioeconomic barriers. In a recent paperwe used this evidence to develop a model that depicts the multiple pathways through which social care interventions appear to operate. SIREN co-directors Laura Gottlieb, Danielle Hessler, and Caroline Fichtenberg discussed the new model and its implications for future program investments and evaluations. 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.

Although there is no question that adverse social circumstances negatively impact health and healthcare outcomes, it is not clear what the healthcare sector’s role should be in addressing these adverse social factors. On February 28, 2024, SIREN Co-Director Caroline Fichtenberg moderated a lively discussion with three thought-leaders on their perspectives on this important question: 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.

Social care practice and research are often inspired by intentions to advance health equity. However, social care is often planned and executed without a clear recognition of and confrontation with the racism, particularly anti-Black racism, that has led to existing inequities. While the legally-sanctioned enslavement of Black people in the United States was abolished in 1865, many of its aims have been perpetuated through residential segregation, the War on Drugs, and the school-to-prison pipeline, to name a few examples. The SIREN National Research Meeting kicked off on September 15, 2022 with a challenge to our moral imagination: In what ways would social care benefit from the contemporary theory and practice of abolition movements in other sectors? In this opening plenary session, physician, scholar, and thought leader Rhea Boyd facilitated a discussion with legal professor and ethicist Osagie Obasogie and education scholar Darion Wallace. Discussants explored how abolitionist thinking has been applied in other fields, including the legal system and school-based education and ways to re-imagine types of social care that cultivate healing and racial health equity. Publications mentioned in this session: Becoming AbolitionistsTorn ApartThe End of PolicingPushout“Just what is afropessimism and what’s it doing in a nice field like education?: Unpacking new contributions to Black educational thought”

Health research remains ensconced in a heavily positivist, reductionist, settler-colonial, racial-capitalist “ritual” of knowledge extractivism and expropriation wherein credentialed researchers mine marginalized communities for data to (re)package and (re)distribute as their (our) own knowledge. Much of this work has focused on racial health inequities while, curiously, leaving unexamined matters of positionality, epistemic equity, and procedural justice in the production and curation of knowledges/narratives about racialized subjects (here, perhaps better described as “objects”). In the US, this production is dominated and curated mostly by White scholars—from tenure-track faculty positions, to funding review panels, to editorial boards, to peer-review bodies. In short, the public/medical health knowledge production and curation enterprise is structurally racist, and it is time that we confront the inherent contradictions of a health equity discourse that fails to interrogate the racialized power dynamics that animate it. Moreover, it is time that we remix the canon and forge a future health research capable of doing our health narratives epistemic—and poetic—justice. In this spirit, social epidemiologist and poet Professor Ryan Petteway draws from social epidemiology, critical, critical race, Black feminist, and decolonizing theory literatures to engage poetry as a site of “radical openness and possibility” (hooks)—an inclusive space of resistance for the production of counternarratives within discourse of health (in)equity. Dr. Petteway presented two poems at the SIREN 2022 National Research Meeting: Racial Health Equity in Social Care. “Something, Something, Something by Race, 2021” and “RELATIVES//Risks” enact public health critical race praxis (Ford & Airhihenbuwa) principles of “voice” and “disciplinary self-critique” as mode of resistance to counter the epistemic violence of our structurally racist and racial-capitalist health inequities research enterprise. In each poem, Petteway foregrounds considerations of epistemic justice/oppression, data (in)justice, and narrative power—illustrating poetry as praxis to challenge public health’s history of violence against our bodies, its (re)colonization of our lives, and its (a)political silence on matters of epistemic and social injustice. These works suggest the epistemological, ethical, and material imperative of remixing/reimagining health knowledge production, expression, and curation practices to more fully—and unapologetically—"center the margins,” with poetry a necessary format of health equity discourse for resistance and healing. Poems: "something something something by race, 2021" Available here. "RELATIVES//Risks" Available here.

Each year an increasing number of original research articles are published about healthcare-based social care programs and policies. However, relatively few of these studies measure the impact of social care interventions on different racial or ethnic minority groups. More information about differential impacts could help to improve the implementation – and ideally the impacts – of social care. During the SIREN 2022 National Research Meeting: Racial Health Equity in Social Care, physician scientists Crystal Cené and Monica Peek briefly shared findings from a recent review they co-led, funded by the Patient Centered Outcomes Research Institute (PCORI), which involved a collaboration with researchers from both RTI and SIREN. Drs. Peek and Cené in this fireside chat explored what counts as measuring racial health equity (including how they developed a novel framework on “thoughtfulness” and “informativeness”), how much (or little) racial health equity has been explicitly described or measured in the social care interventions evidence base to date, and concrete next steps for researchers and practitioners that can strengthen the racial health equity implications of their work. Reference: Cené CW, Viswanathan M, Fichtenberg CM, et al. Racial health equity and social needs interventions: a review of a scoping review. JAMA Netw Open. 2023;6(1):e2250654. doi:10.1001/jamanetworkopen.2022.50654

The final panel at the SIREN 2022 National Research Meeting: Racial Health Equity in Social Care featured four Experts by Experience (Lisa Hamlett, Mike McNear, Ann Reynoso, and Stephanie Walker) as they reflected on their takeaways from the meeting, expressed what was most important to them, and pointed out opportunities for more research and action. The goal of this session was for participants to leave the SIREN National Research Meeting feeling grounded in what mattered to patients with lived experience of racism and socioeconomic challenges, fired up about working in ways that actively promote racial health equity, and focused on what comes next. The panel was moderated by Tanissha Harrell and Rebekah Angove.

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 https://training.cochrane.org/essentialshttps://www.nationalcomplex.care/our-work/https://www.qualityhealth.org/bree/topic-areas/social-determinants-of-health/https://www.publicagenda.org/wp-content/uploads/2019/08/itsAboutTrust_UHF_Final.pdfhttps://media.npr.org/assets/img/2017/10/23/discriminationpoll-african-americans.pdfRaising 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: https://www.southcentralfoundation.com/services/research/"Engaging stakeholders in integrating social determinants of health into electronic health records: a scoping review"Conceptualizing resilience in adult mental health literature: A systematic review and narrative synthesisThe American Indian Holocaust: healing historical unresolved griefAlaska Native Values for the Curriculum (uaf.edu)Our Values – Cultural Center and Museum in Anchorage, Alaska (alaskanative.net)Traditional Values of Alaska posterSharing Our Pathways Volume 11, Issue 1 (uaf.edu)Connor-Davidson Resilience ScalePsychometric Properties of the Connor-Davidson Resilience Scale With Older American Indians: The Native Elder Care Study

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: PDF downloadMilestones for Community-Integrated Health Care at Essential HospitalsPatient Trust: A Guide for Essential HospitalsThe 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: Episodes highlighted in this wrap party: Challenging Racist Systems, Processes, and Analyses in Social CareTo Scale or Not to Scale: Social Risk Screening and the US Health Care SystemThe Intersection of Racism, Discrimination, and Social Risk Screening in Clinical SettingsWhy and How a Health Center Created a Social EnterpriseCommunity-Hospital Collaborations to Improve NeighborhoodsThe Health Care Anchor ModelDelivering Social Care in the Virtual FrontierCommunity Health Workers and Social Care IntegrationUsing Clinical Decision Support Tools to Contextualize CareTaking 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 storeHow do Community Health Centers Pay for Social Care Programs?Emancipators Initiative (webpage)“Out of prison, soapmaking offers a clean start”CrosscurrentsStructural Competency Meets Structural Racism: Race, Politics, and the Structure of Medical Knowledge

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: ARC Resource Library (website)Case study: Anchors in Resilient CommunitiesLegal & Policy Strategies for Health Care & Food System PartnersFood Procurement for a More Just Food System

This episode features a conversation between Bich Ha Pham, JD, the Director of Communications and Policy at the Healthcare Anchor Network, and Mike Koprowski, MA, Ed.M, who is the National Campaign Director at the National Low Income Housing Coalition. This is the fourth in a series of six Coffee & Science events on topics related to Alignment and Advocacy, which are the last two “A”s of the National Academy of Medicine’s framework that SIREN has used to organize Coffee & Science. Alignment and Advocacy are both about what health care can do at the community level to address social conditions. This conversation explores why and how health care organizations should engage in federal advocacy on issues like housing affordability. Recommended references: The Healthcare Anchor Network (website)Principles for Health and Affordable HousingCurrent calls for action from the Opportunity Starts at Home campaignOutside Their Comfort Zone: Health Sector Players Speaking Up for Housing Policy ChangeHealthcare lobbying on upstream social determinants of health in the US

This episode features a conversation between Kelly Kelleher, a pediatrician and Vice President for Community Health and Community Health Services Research at Nationwide Children’s Hospital, and Reverend John Edgar, who is the Executive Director and Pastor Emeritus at United Methodist Church & Community Development for All People. This is the third in a series of six Coffee & Science events on topics related to Alignment and Advocacy, which are the last two “A”s of the National Academy of Medicine’s framework that SIREN has used to organize Coffee & Science. Alignment and Advocacy are both about what health care can do at the community level to address social conditions. This conversation explores how a children’s hospital and faith-based community development corporation have partnered to improve health and health equity in disadvantaged neighborhoods in Columbus, Ohio. Recommended references: A community development program and reduction in high-cost health care useHow Should Health Care Organizations and Communities Work Together to Improve Neighborhood Conditions?Anchors Partnering to Achieve Community TransformationThe Healthy Neighborhood, Healthy Families InitiativeFacilitating Communication for Population Health on Columbus' South SideHow a Risk-Averse Hospital and a Risk-Taking CDC Built a Functional PartnershipCase Study: Nationwide Children's Hospital: An Accountable Care Organization Going Upstream to Address Population Health