Addressing Social Determinants of Health: A Care Coordination Approach for Professional Case Managers.

PURPOSE: Social determinants of health (SDOH) continue to gain attention as the factors that weigh heavily on physical and mental health. In response, professional case managers need to develop a deeper understanding of the entrenched nature of SDOH, particularly the spiraling and compounding effects of economic, environmental, and social factors on the health and well-being of individuals and populations. Professional case managers are essential to helping identify both the barriers experienced by individuals in accessing and receiving the care they need and the resources to eliminate or mitigate those barriers. These responsibilities should be most keenly felt by case managers who are board-certified and therefore held accountable by codes of ethics to ensure justice and fairness. By embedding greater awareness of SDOH into the case management process-from intake and assessment through implementation, evaluation, and across care transitions-case managers can establish rapport with clients (known as "patients" in some care settings) and support improved outcomes through best practices in care coordination, thus contributing to the Triple Aim of improving the health of people and populations and reducing the per capita cost of care.

PRIMARY PRACTICE SETTINGS: SDOH impact individuals across the health and human services, including acute care, subacute care, primary care, community-based care, and workers' compensation.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Case management plays a vital role in providing people with episodic care and ensuring adequate follow-up. The latter includes if and how people are able to access the ongoing care they need, including medications (access and affordability), doctors' visits, therapies and other services, healthy nutrition, and more. However, a lack of affordability undermines an individual's ability to receive preventive care and treatment of chronic illnesses and potentially more serious and life-threatening conditions such as cancer. Compounding the impact of affordability can be a lack of transportation that inhibits access to health care professionals, which can affect individuals in both rural and inner-city environments. Although poverty and homelessness play a direct role in SDOH, case managers cannot assume which clients are impacted by these factors and which are not. Higher costs of living, loss of job or reduced income, unexpected expenses, and death of, or divorce from, a partner/spouse can negatively impact a client's ability to access and afford care. With this understanding, case managers can meet individuals where they are to explore how SDOH affects their lives, without judgment, bias, or assumption.