Assist challenging patients by incorporating information about social determinants of health into the case management arsenal

Case managers working with high-cost or high-need patients should examine the social determinants of health (SDOH) to better assist patients with transitions of care and self-care, according to CMSA Today.

Assessing a patient’s SDOH means examining economic stability, education and job training, environmental conditions, availability and accessibility to healthcare, and social and community factors.

To dig deep into SDOH, case managers must often ask difficult questions of their patients. Case managers can start by asking about the following:

• Housing: What is the quality of the patient’s housing or built environment?
• Income and employment: Is the patient employed or receiving supplemental income?
• Support systems: Does the patient have family members, friends, or neighbors who can assist him or her?
• Food security: Does the patient worry he or she will run out of food before getting the money to buy more?
• Neighborhood crime: Does the patient feel safe in his or her neighborhood?
• Health literacy: Is the patient capable of understanding and processing his or her health condition and care plan?
• Access to providers (e.g., transportation): How long would it take the patient to travel to a provider? Are the means of transportation and the route safe for the patient?

The questions in the list above are only samples of what a case manager might ask, and there are many more ways to ask about each of these topics in order to help case managers uncover barriers to self-care that may not be apparent during a history and physical. Assessing patients early in their care and communicating with the patient’s family or caregiver about SDOH can be key to better assist patients during transitions of care.  

Following the assessment, if a case manager identifies SDOH that may impact the patient’s adherence to a care plan or overall health, he or she should look for resources in the patient’s community that are convenient and do not have restrictive requirements to which the patient may fail to adhere. By broadening the traditional case management approach, case managers can help provide better and more well-rounded care for high-cost or high-need patients.