In November 2024, the Center for Medicare and Medicaid Innovation (CMMI) released the third evaluation report of the Accountable Health Communities (AHC) Model, in which Medicaid and Medicare beneficiaries in 28 communities were screened for social risks and offered navigation to help resolve identified risks. The 177-page report is chock full of interesting findings. On May 8th Dawn Alley, former director of the AHC Model at CMMI and Head of Scale at IMPaCT Care and SIREN Co-Directors Caroline Fichtenberg and Danielle Hessler-Jones unpacked the report’s findings.
The closing plenary discussion at the SIREN 2025 National Research Meeting: Advancing the science of social care, occurred on February 4, 2025 and featured a conversation with health and social care leaders Damon Francis, Monica Soni, Palav Babaria, and Sanjay Basu. Speakers explored multiple social care initiatives being taken to scale and offered their insights about how to navigate this work within a rapidly changing federal policy landscape.
Content from the 2025 SIREN National Research Meeting can be viewed here: https://sirenetwork.ucsf.edu/2025-national-research-meeting
This podcast was made possible through support from the Robert Wood Johnson Foundation and Kaiser Permanente.
This plenary session held on February 3, 2025 at the SIREN 2025 National Research Meeting: Advancing the science of social care featured a discussion between moderator Anand Shah, Vice President of Social Health at Kaiser Permanente, and panelists Stuart Butler, Scholar in Residence of Economic Studies at The Brookings Institution, and Len Nichols, professor emeritus of Health Policy at George Mason University. (Note: Dr Nichols joined virtually.) The panel explored the rapidly shifting sands of social care policy under the new administration. Panelists shared lessons from other periods in the country’s past and offered suggestions for adapting to new practical realities while staying committed to values that underpin social care.
Content from the 2025 SIREN National Research Meeting can be viewed here: https://sirenetwork.ucsf.edu/2025-national-research-meeting
This podcast was made possible through support from the Robert Wood Johnson Foundation and Kaiser Permanente.
The opening plenary session on February 3, 2025 at the SIREN 2025 National Research Meeting: Advancing the science of social care, featured keynote speaker Lauren Taylor, an assistant professor in the Department of Population Health at NYU Grossman School of Medicine, where she is jointly appointed in the Division of Healthcare Delivery Science and the Division of Medical Ethics. In her talk, “Whose job is it, anyway? Exploring the ethics of health care's involvement in social care,” Dr. Taylor dove into the question of whether it is the responsibility of the health care sector to provide social care. She brought insights from ethics, political philosophy, and management science to help the audience make decisions that simultaneously reflect the needs of both current and future sociopolitical conditions.
Content from the 2025 SIREN National Research Meeting can be viewed here: https://sirenetwork.ucsf.edu/2025-national-research-meeting
This podcast was made possible through support from the Robert Wood Johnson Foundation and Kaiser Permanente.
Medicaid community reinvestment requirements enable states to require or incentivize state contractors to reinvest in the communities they serve. State laws, waivers, and contracts that include community reinvestment provisions have specified reinvestments (using percentage of profits and/or performance measures) in community initiatives that align with the state’s key priorities, e.g., improving healthy food access. On January 14, 2025, the UCSF Social Interventions Research & Evaluation Network (SIREN) and the Center for Health Law & Policy Innovation of Harvard Law School hosted a webinar to learn more about these innovative approaches and planned evaluations from state Medicaid leaders and other population health research experts. The target audience for this webinar includes health care providers, social care providers, health policy practitioners, policymakers, and researchers.
SIREN was excited to partner with Futures Without Violence on a two-part webinar series this season. In the second event held on December 5, 2024, speakers shared their lessons learned about sustainable and equitable approaches to documentation/coding and intervention, which are relevant not only to intimate partner violence but also to other social drivers of health.
This webinar is made possible with support from Blue Shield of California Foundation and Kaiser Permanente.
SIREN partnered with Futures Without Violence on a two-part webinar series this season. On November 5th, 2024 speakers discussed evidence-based and healing-centered approaches for responding to intimate partner violence and share strategies shown to enable and sustain meaningful partnerships with community-based programs.
This webinar was made possible through support from the Blue Shield of California Foundation and Kaiser Permanente.
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:
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.
