Care managers play a pivotal role in addressing social determinants of health (SDoH) for their patient populations. With eyes on all patients in the group as well as a comprehensive understanding of the resources available, care managers have a unique vantage point, empowering them to make a big impact on their patients, especially when considering SDoH risk factors.
Similar Comorbidities, Different SDoH Risk Factors
Let’s consider two patients. Patient A, a 76-year-old woman diagnosed with arthritis, cataracts, and dementia. One of the key social determinants affecting Patient A’s health is her isolation and limited social support. She lives alone and has minimal interaction with others due to her cognitive decline and physical limitations. This isolation exacerbates her symptoms of dementia and arthritis, leading to increased mental and physical deterioration.
Patient B, though sharing similar diagnoses with Patient A, including arthritis, cataracts, and dementia, faces different social risks. Patient B is a 73-year-old woman with low socioeconomic status and limited accessibility to transportation, both of which create significant barriers to accessing necessary healthcare services.
Clearly, understanding each patient’s social determinants really matters when deciding on what targeted interventions to give each.
Key Role of Care Managers
- Identifying SDoH: Care managers can use screening tools and patient interviews to identify the SDOH that impacts their patients' health.
- Connecting patients with resources: Once they identify SDoH risk factors, care managers can connect patients with the resources they need to address them. This may include resources such as medically tailored meals, telehealth appointments, or transportation services.
- Advocating for patients: Care managers can advocate for their patients by working with healthcare providers and other stakeholders to ensure they have access to supportive care and services.
- Educating patients and families: Care managers can educate patients and families about SDoH and how these risk factors impact health. Further, this helps patients better understand their health and make informed decisions about their care.
- Tracking progress and outcomes: Care managers can monitor patients' behaviors and outcomes over time to assess the impact of their interventions on SDoH. This information can be used to refine and improve care management practices.
SDoH Informed Interventions
Considering the two patient examples previously mentioned, here’s what targeted intervention recommendations could look like for each. The care manager would note that Patient A’s care plan should prioritize fostering social connections and engagement, given her SDoH risk of isolation. This can be achieved through various interventions, such as arranging regular visits from community volunteers, encouraging participation in social activities at local senior centers, and facilitating connections with support groups for individuals with dementia and arthritis.
An SDoH-informed care manager would tailor a different plan for Patient B, given her low socioeconomic status and lack of transportation. In particular, the care manager might design a plan focusing on providing affordable treatment options and mobility assistance. For example, this may involve connecting her with programs that offer financial assistance for medications. Moreover, including transportation services coordination or exploring telehealth alternatives becomes crucial in addressing the accessibility barriers for Patient B.
A care manager’s understanding of each patient’s social determinants really matters when deciding on what targeted interventions to give.
ACOs Can Support Care Managers
With so much riding on curated care plans, ACOs have the opportunity to support their care managers in addressing SDOH.
- Training and Education: ACOs can offer care managers training and education about SDOH and managing the various risk factors, helping care managers develop the skills and knowledge they need to be effective in their role.
- Resources and support: ACOs can provide care managers with the resources and support they need to succeed in their endeavors to address SDoH risk factors. This may include access to electronic health records, social workers, and other healthcare providers.
- Technology and Platforms: ACOs can further support their care managers by offering tools and platforms. For example, ACOs can implement platforms that leverage up-to-date data to assess the SDoH risk factors of a given patient and offer targeted intervention recommendations.
- Culture of Collaboration: ACOs can foster a collaborative environment among care managers and other healthcare providers, ensuring that care managers are able to effectively coordinate care for their patients.
Ultimately, everyone – providers, patients, care managers, and the ACO – stands to benefit when care managers receive the support they need. By properly empowering care managers, ACOs can see improvement in their ROI and their patient health outcomes.
Further explore the challenges care managers face and how technology platforms like our Equity Equalizer™ platform can help identify health barriers, prioritize patients and improve care delivery in our latest eBook.
