About

Alicia Cohen, MD, MSc, FAAFP, is an Assistant Professor of Family Medicine at the Warren Alpert Medical School at Brown University and an Assistant Professor of Health Services, Policy, and Practice at the Brown University School of Public Health. Her research focuses on understanding and improving processes at the patient, community, health system, and structural levels to address adverse social determinants of health and promote health equity across the lifespan. She has extensively published on social drivers of health, social care integration, food insecurity, and health inequities, with her work being cited in Congressional testimony on Veteran and military hunger. Dr. Cohen co-leads a national VA clinical intervention aimed at screening for and addressing social risks and health-related social needs, known as 'Assessing Circumstances and Offering Resources for Needs' (ACORN), in partnership with the VA Office of Health Equity and the National Social Work Program. She practices primary care at the VA Providence’s Homeless and Women’s Health clinics. Her educational background includes an MD from the Icahn School of Medicine at Mount Sinai, Family Medicine training at UCSF-Santa Rosa, an Integrative Medicine Fellowship at the University of Michigan, and a master's degree in Health and Health Care Research earned during her Robert Wood Johnson Foundation Clinical Scholar program. She also completed an Advanced Health Services Research & Development Fellowship at the VA Ann Arbor Center for Clinical Management Research and VA Providence Center of Innovation in Long Term Services and Supports. Dr. Cohen has been recognized as a James C. Puffer/American Board of Family Medicine Fellow with the National Academy of Medicine and a VA Fellow on the National Academies of Sciences, Engineering, and Medicine Roundtable on the Promotion of Health Equity.

Research topics

• Medicine
• Environmental health
• Family medicine
• Nursing
• Gerontology
• Psychology
• Psychiatry

Selected publications

• Embracing Co-Design and Interprofessional Teamwork to Build an Innovative Dashboard for a National Social Needs Screening and Referral Clinical Intervention in the Veterans Health Administration: Design and Development Study

  Journal of Medical Internet Research · 2026-02-25

  articleOpen access

  Background: Assessing Circumstances and Offering Resources for Needs (ACORN) is a US Department of Veterans Affairs (VA) clinical intervention designed to identify and address social needs to improve health and well-being among all veterans. We co-designed the ACORN Dashboard to facilitate access to real-time social needs and intervention data for VA clinical care teams and leadership. Objective: This study aimed to (1) describe the iterative development of the ACORN Dashboard, (2) assess end user feedback and Dashboard usage, and (3) discuss the role of social needs dashboards in facilitating continuous quality improvement in health care settings. Methods: An interprofessional team of subject-matter experts and end user feedback contributed to the design. Phase 1 included more than 7 months of weekly working meetings. We initially constructed a wireframe in Microsoft PowerPoint, then translated it into a prototype in Power BI, a data visualization software. Using Microsoft Power BI, we built data visualizations to communicate population-level sociodemographic and ACORN screening data. Through feedback sessions, staff from 8 VA medical centers (VAMCs) reviewed the prototype and recommended improvements regarding the Dashboard's purpose, content, and usability. Phase 2 involved 6 weeks of weekly working meetings, where we developed and iteratively refined 5 written drafts of clinically relevant variables for potential inclusion in the Patient-Level Data Page. This list informed a Power BI prototype. We also developed the ACORN Implementation Map page in Power BI to display implementation locations and settings. We again used feedback sessions with 8 VAMCs to review and refine the newly added pages and discuss improvements. To assess usage, we obtained metadata from a VA-specific Power BI report and user experience data from an ACORN VAMC survey. Results: The ACORN Dashboard displays national data that are updated daily, reflecting 83,546 screens administered across 82 VAMCs facilities between July 1, 2021, and April 30, 2025. The Dashboard was viewed 18,192 times by 2251 unique users, and, on average, 263 (SD 91.2) unique users viewed the Dashboard every month between October 1, 2023, and April 30, 2025. Dashboard variables include the number of screens completed, sociodemographic characteristics of veterans screened, prevalence of social needs, and interventions provided to address needs. Phase 1 semistructured feedback sessions included recommendations for a page with patient-level data to supplement the population-level pages, incorporation of additional filters to select specific data, and development of a user guide. In phase 2, key insights included enhancement of end users' ability to search by veteran or staff name, guidance about screening frequency, changing the display order of variables, and the inclusion of variable definitions. Conclusions: Using co-design to develop, maintain, and continually refine data dashboards enhances implementation of social screening and interventions in health care settings. In addition to supporting individual-level patient care, population-level dashboard data inform continuous quality improvement, promote health equity, and identify gaps in services to address identified needs.

  PublisherDOI

• Prevalence of 19 Social Risks in a National Survey of Veterans Health Administration Patients

  Journal of General Internal Medicine · 2026-05-18

  article
  PublisherDOI

• Understanding the Reasons Why Patients With Food Insecurity Decline Social Assistance at a Large Academic Medical Center

  AJPM Focus · 2025-02-07 · 3 citations

  articleOpen access

  Introduction: Despite the recent expansions of clinical screening for food insecurity, research shows large discrepancies between the number of patients who report food insecurity and those who request assistance. In this qualitative study of patients with food insecurity who declined social assistance, the authors aimed to understand the patients' reasons for not seeking food-related assistance and explore their perspectives on addressing food insecurity with their healthcare provider. Methods: At a large academic medical center in southeast Michigan, the authors conducted semistructured, in-depth interviews with 31 English-speaking adult primary care patients who had screened positive for food insecurity at a previous clinic encounter and subsequently declined assistance from a trained social worker. The interview guide explored patients' reasons for declining social assistance, perspectives on clinical screening for food insecurity and other social risk factors, and the extent to which they discussed their needs with their provider. Interviews were recorded, transcribed, and analyzed using the constant comparative method to reveal emergent themes. Results: The mean age of the participants was 48.2 years, and 71% were women. The most prominent reasons for patients with food insecurity not seeking social assistance were the belief that the potential resources would be redundant or not helpful and previous negative experiences with receiving food assistance. Several patients also did not remember or know that they had declined assistance. Most patients believed that healthcare providers should be knowledgeable about patients' food insecurity status to better inform care delivery. However, patients expressed discomfort, fear, or embarrassment in revealing this information and emphasized the importance of providers fostering a supportive and empathetic healthcare environment. Conclusions: Strategies to connect patients with food assistance must target multiple levels, including improving assistance methods, increasing provider knowledge, and prioritizing patient comfort.

  PublisherOA PDFDOI

• Food Insecurity and Diabetes Risk: Understanding the Role of Body Mass Index as a Mediator and Moderator

  Current Developments in Nutrition · 2025-05-01

  articleOpen access
  PublisherDOI

• Associations Between Social Risks and Obesity in High-risk Veterans

  Journal of General Internal Medicine · 2025-12-08

  articleOpen access
  PublisherOA PDFDOI

• Health-related social needs and mortality risk among United States Veterans with non-small cell lung cancer.

  Journal of Clinical Oncology · 2025-05-28

  article

  e13750 Background: Multiple expert bodies recognize screening and referrals for health-related social needs (HRSNs) as vital components of comprehensive and equitable cancer care. However, systematic HRSNs screening in oncology settings remains limited, with little data available regarding the clinical adoption or reach of screening interventions. We evaluated HRSNs screening rates among Veterans newly diagnosed with non-small cell lung cancer (NSCLC) and assessed the impact of HRSNs on stage at diagnosis and overall survival (OS). Methods: We conducted a retrospective cohort study of patients diagnosed with NSCLC at the Veterans Health Administration (VHA) across all 18 Veterans Integrated Service Networks from 01/01/2013-12/31/2021. Data on HRSNs screenings completed within 3 months after NSCLC diagnosis were extracted from structured data fields in clinical social work assessment notes and VHA clinical screeners for food insecurity, housing instability, and intimate partner violence. We used multivariable logistic regression and Cox proportional hazards models to evaluate the association of HRSNs with stage at diagnosis and 5-year OS, respectively, adjusting for age, sex, race, clinical stage, histologic type, Charlson-Deyo comorbidity index (CCI) score, area deprivation index (ADI), and year of diagnosis. Results: A total of 62,902 Veterans (mean age: 70.7 years; median follow-up: 6.6 years) met inclusion criteria. The distribution of NSCLC stages is shown in Table 1. Only 13,145 (20.9%) Veterans had ≥1 documented screens for HRSNs in the first 3 months following receipt of their NSCLC diagnosis. Among these, 5,515 (42.0%) screened positive for ≥1 HRSNs on their index screen. Compared to Veterans who screened negative, those with a positive index screen were significantly more likely to be Black (19.5% vs. 17.4%, p = 0.012), have multiple comorbidities (mean CCI score: 2.7 vs. 2.4, p < 0.001), and reside in higher ADI areas (mean ADI: 60.4 vs. 59.1, p < 0.001). In multivariable analyses, Veterans with a positive index screen had significantly elevated odds of diagnosis with late-stage NSCLC (III/V vs. I/II: adjusted odds ratio 1.812, 1.681-1.949) and reduced adjusted 5-year OS across all disease stages (I: 48.8% vs. 54.7%; II: 32.1% vs. 38.5%; III: 16.7% vs. 22.4%; IV: 1.8% vs. 3.1%, p < 0.001), compared to those who screened negative. Conclusions: HRSNsscreening is infrequently performed among Veterans newly diagnosed with NSCLC. Veterans with HRSNs are more likely to be diagnosed with late-stage NSCLC and experience reduced OS. There is a critical need to enhance systematic screening for HRSNs and processes to address identified HRSNs among Veterans with NSCLC. NSCLC stage distribution. Clinical Stage Total Patients, N=62,902 (%) Patients Screened, N=13,145 (%) I 23,834 (37.9) 4,478 (34.1) II 6,942 (11.0) 1,419 (10.8) III 13,435 (21.4) 2,975 (22.6) IV 18,691 (29.7) 4,273 (32.5)

  PublisherDOI

• Contextualizing Age‐Friendly Care Within Social Drivers of Health

  Journal of the American Geriatrics Society · 2025-11-11

  articleOpen access

  Social drivers of health (SDOH) impact health outcomes across the lifespan, with distinct effects on the health and well-being of older adults. SDOH contribute to outcomes of particular importance to older adults, including physical and cognitive functioning and aging in place, highlighting the critical importance of addressing SDOH as part of comprehensive, patient-centered geriatrics care. Yet, there is limited guidance on best practices for the integration of SDOH into healthcare, particularly in subspecialty clinical settings such as geriatrics. Existing geriatrics frameworks, including Age-Friendly Health Systems and the Geriatrics 5Ms, provide an opportunity to incorporate SDOH concepts, as they are naturally aligned with models of social and medical care integration. Building on existing frameworks, we propose a novel conceptual model that integrates SDOH across the geriatrics care continuum, including practical guidance for geriatrics healthcare professionals to proactively incorporate SDOH into Age-Friendly care.

  PublisherOA PDFDOI

• A partner‐informed approach to prioritizing social risks for research in a learning health system

  Learning Health Systems · 2025-04-10 · 1 citations

  articleOpen access

  Abstract Objective To prioritize social risks (individual‐level social and economic conditions) that may influence a person's health for inclusion in a national survey of Veterans Affairs (VA) healthcare system patients. Data Sources and Study Setting Quantitative ratings of candidate survey measures were obtained from a national Advisory Group of researchers, clinicians, Veterans, and VA operations leaders; qualitative input was collected from the Advisory Group and Veterans. Study Design We solicited input on social risk prioritization across four phases: (1) candidate social risks were identified through a literature review and existing screening tools, (2) Advisory Group members ( n = 15) individually and anonymously rated social risks on four criteria (impact on health outcomes, impact on patient experience, actionability, and overall prioritization), (3) the Advisory Group discussed collective ratings and provided qualitative feedback about candidate social risks, and 4) Veterans ( n = 29) provided qualitative feedback about the draft survey during four Veteran Engagement Group meetings and in survey pretesting with individuals ( n = 5). Data Collection/Extraction Methods Selection of social risks for survey inclusion was based on an a priori definition of a social risk and relevance to Veterans (phase 1), quantitative and qualitative input from the Advisory Group (phases 2 and 3), and qualitative Veteran input (phase 4). Principal Findings An initial list of 37 social risks was pared down to 18 for inclusion in a national survey: financial strain, health care/medicine access and affordability, food insecurity, homelessness/housing insecurity, transportation barriers, digital access/literacy, utilities insecurity, social support, caregiver responsibilities, discrimination experiences, interpersonal violence, education, employment, health literacy, legal problems or exposure to the justice system, race/ethnicity, gender identity, and sexual orientation. Conclusions Our partner‐informed approach combining quantitative and qualitative input offers a road map for other learning health systems seeking to prioritize social risks for evidence generation.

  PublisherOA PDFDOI

• An Innovative Nurse Navigator Approach to Screen For and Address Social Needs in a Veterans Health Administration Women’s Health Clinic

  Medical Care · 2025-09-12 · 1 citations

  articleOpen accessCorresponding

  BACKGROUND: Women Veterans are the fastest-growing population in the Veterans Health Administration (VHA), but little is known about how to identify and address their social needs. This program evaluation examined the implementation of a social screening and referral initiative, Assessing Circumstances and Offering Resources for Needs (ACORN), using nurse navigators in a VHA women's health clinic. OBJECTIVES: (1) Describe the implementation process and outcome measures, (2) assess the prevalence of women Veterans' social needs, (3) characterize nurse navigators' perceptions of ACORN, and (4) document implementation challenges and adaptations. RESEARCH DESIGN: Program evaluation with qualitative and quantitative data collected between March 2023 and November 2024. Descriptive statistics were used to summarize sociodemographic characteristics and social needs of Veterans screened. SUBJECTS: Veterans receiving continuity care at a women's health clinic in a midwestern VHA hospital. RESULTS: Nurse navigators completed ACORN screens with 291 Veterans, with 67% screening positive. The most frequently reported needs were social isolation/loneliness (49%), utilities (17%), transportation (14%), and digital needs (13%). Nurse navigators and the nurse site champion reported that ACORN enhanced their understanding of patients' social needs and their ability to address these needs. They also reported seamless integration of ACORN into existing workflows. CONCLUSIONS: Findings show early insights into women Veterans' unique social needs. An innovative nurse navigator approach to social screening in a VHA women's health clinic was feasible, had high likelihood of sustainment, and improved nurses' ability to care for their patients. This indicates strong potential for expanding nurse navigator roles both within and outside VHA.

  PublisherOA PDFDOI

• Food insecurity and the risk of diabetes: understanding the role of BMI as a mediator and moderator

  Obesity · 2025-06-17

  articleOpen access

  OBJECTIVE: This retrospective cohort study examined BMI as a mediator and moderator of the association between food insecurity and diabetes. METHODS: Data came from the electronic health records of 74,174 primary care patients at a large academic medical center. We used multivariate Poisson regression models to examine the association between food insecurity and diabetes. We used causal mediation analysis to evaluate the direct and indirect effects by which BMI mediates and moderates this association and the extent to which these effects varied by age, sex, and race and ethnicity. RESULTS: During the 5-year period, 6.2% of patients were newly diagnosed with diabetes. Food insecurity was associated with a higher risk of diabetes (relative risk [RR] 1.19, 95% CI: 1.03-1.36) after multivariate adjustment. In mediation analysis, BMI was a significant mediator of the association between food insecurity and diabetes (natural indirect effect: RR 1.10, 95% CI: 1.06-1.14). When accounting for an interaction with BMI, BMI remained a significant mediator (natural indirect effect: RR 1.12, 95% CI: 1.0-1.17). In subgroup analyses, the mediator-moderator effect of BMI was stronger among adults <45 years old and female patients; there were no differences by race or ethnicity. CONCLUSIONS: Our findings support BMI as a mediator and moderator of the association between food insecurity and diabetes.

  PublisherOA PDFDOI

Frequent coauthors

• Elena Byhoff

  University of Massachusetts Chan Medical School

  88 shared

• Matthew M. Davis

  Lurie Children's Hospital

  70 shared

• Renuka Tipirneni

  University of Michigan–Ann Arbor

  68 shared

• Mary C. Hamati

  University of Colorado Denver

  64 shared

• Julie Tatko

  Northwestern University

  64 shared

• Eric W. Fleegler

  Boston Children's Hospital

  51 shared

• Ellen Poleshuck

  University of Rochester Medical Center

  49 shared

• Colleen T. Fogarty

  University of Rochester Medical Center

  49 shared

Education

• M.D.

  Icahn School of Medicine at Mount Sinai

• M.S., Health and Health Care Research

  University of Michigan

• B.S., Family Medicine

  UCSF-Santa Rosa Family Medicine Residency

• Other, Integrative Medicine

  University of Michigan

• Other, Advanced Health Services Research & Development

  VA Ann Arbor Center for Clinical Management Research and VA Providence Center of Innovation in Long Term Services and Supports

Awards & honors

• 2022-2024 James C. Puffer/American Board of Family Medicine…
• 2022-2025 VA Fellow on the National Academies of Sciences, E…