Navigating the Social Care Landscape: Five Lightbulb Moments from the SIREN National Research Meeting

Back in 2021, I was working as a public health consultant and became increasingly interested in the role healthcare plays in supporting a patient’s social care needs. A colleague at the time put me onto Coffee & Conversations, a research-based podcast hosted by the SIREN Network exploring the science of social care. It is largely because of this podcast that I left my career in consulting and made my way to Azara Healthcare – a company that I knew was equipping health centers with the technological capabilities and analytical insights to formalize this work and make it successful. Needless to say, I was overjoyed when a poster submitted in collaboration with Community Health & Wellness Partners of Logan County, Ohio, was accepted and I found myself booking flights to San Diego.  

The energy I felt walking into the conference center for the Welcoming Remarks was palpable. The conference couldn’t have been timelier. Earlier that day, I woke to the news that the new administration banned all mention of health equity from government websites. Later I strolled to the waterfront and witnessed hundreds of people marching in protest of the recent mass deportation of migrants in San Diego. Over the course of two days, I learned from and convened with over 400 other professionals in the field, and while we were united by a collective sense of fear and grief, there was also a profound sense of hope and promise.

I left with twelve pages of handwritten notes, and while I could never convey all the magic that transpired during my time there, I felt compelled to distill these notes to my top five lightbulb moments with the hopes that they might spark some electricity and inspiration to others who are as passionate about this work as I am.  

1. Embrace a “Bifocal” Approach to Addressing Social Needs 

Lauren Taylor, an assistant professor at NYU Grossman School of Medicine, led the opening plenary and addressed the ongoing debate: Is it really healthcare’s responsibility to address society’s structural shortcomings related to housing, education, transportation, etc.? She argued that it's unsustainable for healthcare to shoulder social care responsibilities long-term, though completely removing it in the short term isn't feasible. Taylor suggested adopting a "bifocal approach," addressing current realities while aiming for a future where social care responsibility could shift back to the community. 

2. Adopt an Impact Investment Lens to Return On Investment (ROI)  

Health centers often inquire about how to best capture the value of social care interventions, like adopting social needs screenings, hiring community health workers, or expanding referral workflows to include community-based referrals. One presenter suggested drawing lessons from impact investing. Unlike traditional ROI focused on cost savings, impact investing highlights avoided costs through prevention. A compelling example showed how funding patients directly reduced homelessness by 15x and led to other benefits, like improved mental health, employment retention, and lower public sector costs. Adopting this impact-investing framework could help health centers demonstrate the long-term value of social care investments. 

3. Avoid the “Widgetization” Risk 

Incorporating social care into healthcare is challenging because there’s an inclination to apply the same rigor used in clinical care. While clinical protocols are strictly defined to reduce errors and ensure consistent outcomes, social care is more complex—it requires a unique degree of trust and patient-centeredness to facilitate an environment where patients will disclose sensitive and personal factors like food insecurity or intimate partner violence. One presenter aptly described this tension as the “widgetization risk,” where applying clinical rigor to social care threatens to reduce the process to mere metrics, diverting attention from addressing patients’ real needs. Balancing structured protocols with empathy and flexibility is crucial to ensuring social care remains meaningful for patients and communities. 

4. Navigate the Tension Between Reporting & Coding Ethics 

As an Azara employee, I am naturally a strong advocate for the collection of data, as it is through data that we can assess the effectiveness of care delivery and identify opportunities for improvement. However, several presenters raised concerns about collecting and reporting social drivers of health data. A Clinical Instructor from Harvard Law highlighted the growing demand to collect social care data for reporting, accreditation, and reimbursement, but stressed the importance of educating staff on how sensitive data is gathered and documented. Social care data is not legally protected, meaning it could be used in court or leveraged in other legal proceedings. Health centers must document carefully, as incomplete records can have unintended consequences. Training staff to reduce biases, conduct patient-centered screenings, and understand mandatory reporting can help ensure accurate data collection and informed action. 

5. Act Hyperlocal in the Face of Uncertainty 

Amid uncertain funding conditions and threats to Medicaid coverage, many attendees asked presenters how they could find the strength and motivation to move forward. The response across presenters was consistent: act hyper-local. One presenter referenced the National Academies of Science’s piece, Implementing High Quality Primary Care, which outlines the ways in which primary care is a public good. By design, primary care enhances population health, reduces health disparities, strengthens health systems, and reinforces societal stability. Health centers, by serving entire communities, can still provide benefits despite current conditions. Another presenter suggested relying on community alliances and local policies when larger policies are lacking. Strategies like diversifying funding, strengthening local networks, and engaging in advocacy can help health centers meet their communities’ needs and build a resilient local ecosystem. 

Conclusion 

As I reflect on the insights shared at the SIREN National Research Meeting and the larger conversation surrounding the integration of social care into healthcare, I am filled with both optimism and urgency. The challenges are undeniable, but there is great power in the collective efforts of those committed to this cause. Despite the obstacles ahead, the energy and dedication I witnessed during this conference reminded me that meaningful change is possible, and with the right support, collaboration, and community engagement, we can continue to push forward and improve the health and well-being of those we serve.