Drs. Alicia Cohen and Emilia De Marchis provide commentary on three articles in this issue of Annals of Family Medicine, specifically Greenwood-Ericksen et al's research on Michigan's Federally Qualified Health Centers; Hoeft et al's special report about translating lessons learned from behavioral health integration into the social care realm; and Fessler et al's narrative about how they as medical students stepped away from their medical clerkships to act as community volunteers for people experiencing homelessness during the COVID-19 pandemic. All three articles serve as a timely call to action, reminding those in health care that work remains to meet the needs of patients, particularly in screening for and intervening on identified social risks. The urgency of this work has only been heightened by the pandemic as patients face new or intensified socio-economic hardships. Cohen and De Marchis write that collaboration is needed among researchers, policy makers, payers and health care systems to assist in identifying evidence-based practices for social needs integration. This includes improved training and education for all clinical care team members about social risk and social care activities, best practice guidelines, evidence-based interventions, and sustainable funding streams. Social risk data can also more broadly aid advocacy and policy efforts to expand community-based resources, efforts to address health inequities, and population health-level interventions. Cohen and De Marchis note that greater flexibility in using Center for Medicare & Medicaid dollars and the new 2021 Evaluation and Management coding guidelines for social determinants may help with more consistent funding for social care activities. "The path ahead requires working together and sharing learnings to advance our common goal of achieving health equity and wellness--for patients and the health care workforce alike," they write.
