When it comes to one’s overall health and well-being, it is not all about medical treatments, good nutrition and exercise. There are many other non-medical factors that contribute to an individual’s whole person well-being. These factors are known as social determinants of health (SDOH) and include one’s economic situation and job opportunities, housing opportunities, access to nutritious foods and physical activity, access to a quality education, social and community resources, transportation, and language and literacy skills. They are key contributors to widespread health disparities among certain clusters of individuals. Gaining more data to determine just how SDOH affect a person’s well-being, and which social determinants of health have the greatest impact on what groups of people, has become an increasingly important goal of healthcare providers and all members of patients’ clinical team including their case manager. In fact, case managers have a special vantage point in this area as their role involves regular meetings and communication with their patients, monitoring their health progress, patient advocacy, and information exchanges with other members of a patient’s clinical team.
How Case Managers Support SDOH Goals
The Case Management Society of America (CMSA) includes SDOH within its Standards of Practice (CMSA, 2022) for case managers. To support SDOH objectives, case managers’ role encompasses the comprehensive assessment of SDOH inclusive of a patient’s housing, income, education level, food security, social support, and community resources. Also involved in the SDOH initiative is the collaboration with other healthcare providers. Through a multidisciplinary approach, case managers can improve their coordination of care, patient referrals to needed resources (i.e., other clinicians, social workers, community services, legal advocates, etc.) and develop an optimized whole-person care plan.
Their patient advocacy is also critical as it involves raising the awareness of the patient and his/her family regarding the resources that are available to them, while assisting them with how to apply for these resources (e.g., helping with phone calls, applications, meetings, etc.), and generally giving patients a voice in their care. By engaging their patients, they too become catalysts for change in addressing SDOH and mitigating the negative effects on patients’ well-being. Patient engagement also requires patient education, a responsibility of case managers in their core role, but also as applied to SDOH goals.
Finally, case managers are also charged with assessing their impact on a patient’s overall health as related to SDOH that may be affecting it. Using the data captured in their care of a patient and considering it within the context of their SDOH, case managers can then benchmark improvements and further support their specific needs.
The Complex Patient with Comorbidities
Patients with complex medical conditions including comorbidities (e.g., cancer and a heart condition) are approached by case managers in a way to identify their unique SDOH risk factors. Patients with similar comorbidities may have different SDOH risk factors. By tracking each patient’s progress, insights gained from SDOH assessments can be best leveraged to advance care plans, interventions and referrals tailored to all specific patient’s needs.
Case managers are on the frontline of the SDOH mission, connecting patients in vulnerable population groups to the care and resources they need to support their whole person well-being.