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Care Managers Key in Addressing SDoH, Driving Health Equity


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

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.

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. 

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