July 26, 2022

7 min read

Social Determinants of Health: Chronic Care Management Program Role

Part two in a two-part series (access part one)

Imagine calling your chronic care case management patient for their weekly check-in only to find out that they haven't taken their blood pressure medication in four days. While the direct effect of the missed medication is worrisome, even more concerning might be the reason why the patient is skipping doses in the first place. Within chronic care management programs, it's not uncommon to run into these types of patient problems, and these situations probably arise more often than we like, or we'd like to admit. Often, the cause or a significant contributing factor to patient non-adherence with a chronic care management program is social determinants of health (SDoH).

We recently published a post — part one in a two-part series — that discussed the concept of SDoH and highlighted some of the significant social determinants affecting patients today. We also looked at how the right chronic care management solutions can help organizations better navigate the challenges often associated with social determinants of health. 

Now, in part two of this series, we'll explore how chronic care management offers the perfect opportunity to effectively manage the delivery of care for chronic conditions and specifically address obstacles that many patients face every day.

Correlation Between Chronic Disease and Social Determinants of Health

Chronic diseases don't typically appear overnight. They are usually the result of years of poor lifestyle choices, poverty, lack of education, and/or other impactful social determinants of health. Fortunately, chronic care management programs are already helping directly impact and even mitigate the most severe effects of chronic disease. As providers, it's important to be proactive and ready to jump into problem-solving mode to help address our patient's most impactful SDoH and guide them back onto the path of health and wellness. Such efforts often begin with a conversation.

Asking Questions to Help Identify Social Determinants

While it's technically only one piece of the expansive CMS chronic care management program, addressing social determinants of health can undoubtedly play one of the biggest roles in helping patients better manage their chronic conditions and achieve care and wellness goals. However, not all patients are going to be forthcoming about their needs and barriers, and some might not even be aware they have obstacles in their path to better health.

To help reduce the likelihood that patient obstacles go unnoticed, it's important that the chronic care management questions for patients that healthcare providers ask help prompt honest and thoughtful answers from them. For starters, ask open-ended questions that can't be answered with just a yes or no. The goal is to get to know the patient and build a sense of trust and cooperation. For example, just asking the patient if they are eating lower sodium foods will likely result in a "yes" or "no" answer, but asking the patient what types of foods they are eating may garner better details or even open the conversation to whether they are experiencing barriers obtaining healthier food options.

Creative Problem Solving Within Your Chronic Care Management Program

Addressing social determinants of health with patients means identifying obstacles to achieving chronic care goals, the reason those obstacles existing, and utilizing available tools and resources to help patients move past barriers to achieve better health. While solving all patient issues related to SDoH isn't always possible, chronic care management provides a unique opportunity in managing the delivery of care for chronic conditions in a very hands-on manner. Since chronic care case management is high touch with numerous opportunities for patient interactions, care team members can help patients figure out exactly what they need to be successful in their chronic care management program.

Below, we've outlined a few common scenarios of barriers that chronic care management program patients face in real life. While solutions can vary by patient, provider, diagnosis, co-morbidities, and even location, these scenarios can help your care team better prepare for common barriers and develop creative solutions that speak to the unique needs of your organization, location, patient population, and available resources.

Common Social Determinant of Health: Financial Barriers

More than 15 million American adults aged 65 and over live on incomes that are at least 200% below the federal poverty level. Lacking income directly affects one's ability to access and afford regular healthcare, significantly affecting overall health and the ability to be successful in a chronic care management program.

SDoH Challenge

Let's revisit the example discussed in the beginning. A patient tells their chronic care case manager that they haven't taken their prescribed blood pressure medication for several days. When asked why they've been skipping their doses, they state that this medication is not covered by their insurance, and they can't afford to pay for it until their Social Security payment arrives in several more days.

Care Management Approach

After discussing appropriateness with the provider, the case manager could check for available samples of the medication, help facilitate a switch to a payer-covered medication, or reach out to the drugmaker and local pharmacies to find out if there are any patient scholarship programs available. The patient can also be connected to social or senior services to help them find other solutions, like enrollment in Medicaid to help offset out-of-pocket medication costs.

Common Social Determinant of Health: Transportation Barriers

Transportation barriers are quite common, especially among older adults. In fact, according to the results of a poll from the National Aging and Disability Transportation Center, 68% of older adults felt that finding transportation when they needed it was difficult and they often needed to rely on family members to get around. This particular social determinant of health can be even more challenging for patients who live rurally.

SDoH Challenge

A patient has not started the new prescribed medication for their type 2 diabetes prescribed one week ago. When asked why, the patient states that they have no transportation to get to the pharmacy to pick up the new medication.

Care Management Approach

Most insurance plans now allow for mail order prescription services, but patients might not always be aware of this option. Case managers can help patients find out if mail delivery of their medications is a workable solution for their circumstances. Other creative solutions could mean exploring other delivery options like Instacart or even switching to a pharmacy that offers delivery.

SDoH Challenge

A patient has been asked to get new labs drawn prior to the upcoming visit with their provider. When the case manager calls the patient to follow up because the lab results have not arrived, the patient states they have not gone to the lab yet because they do not have access to transportation.

Care Management Approach

Depending on location, transportation services, like a medical taxi program paid for by insurance, may be available. Care team members should compile a list of the specific transportation services available in your local area.

Common Social Determinant of Health: Access to Healthy Food

According to the USDA, 13.8 million U.S. households experienced food insecurity during 2019 and 2020. For patients participating in chronic care management programs who have chronic health conditions like hypertension and diabetes that require diet modifications, this lack of access to healthy food choices can prevent patients from making dietary changes that should positively impact their health.

SDoH Challenge

A patient with hypertension has been advised to reduce their sodium intake. When the case manager calls to check in on the patient's progress in altering their diet, they find out that the patient had a "value meal" cheeseburger, fries, and soda for dinner last night. The patient reveals that they only had $5 to spend on their meal, and that was the cheapest way to have a filling dinner.

Care Management Approach

In a situation like this, the patient is likely experiencing a combination of financial problems, food insecurity, and low health literacy. Without money for healthy meals, it can be difficult to choose healthy options. Without understanding what healthy options are available, the patient is likely to continue to make the same food selection mistakes. To address these issues, care team members can compile a list of low-cost healthy food options and include simple recipes for easy preparation. Care team members can also connect the patient with their local SNAP program or other meal services like Meals on Wheels America to better help ensure healthy meals are paid for, prepared, and even delivered to them.

Common Social Determinant of Health: Social Isolation

Nearly 25% of all adults aged 65 and over are considered to be socially isolated. Unfortunately, social isolation can have a significant negative impact on health, leaving seniors at higher risk for dementia, heart disease, stroke, depression, anxiety, suicide, hospitalization, and even premature death.

SDoH Challenge

A patient has been instructed to get more exercise outside of their home to combat their type 2 diabetes and depression symptoms. When the case manager calls to check in on patient progress, the patient states they are lonely and don't want to go out alone. They also say they can't afford to pay for a gym membership. The patient has no friends or family who live locally to help them.

Care Management Approach

Isolated patients might not realize that their isolation plays a direct role in their health. Regardless of the reason for isolation, the care team can help the patient connect with social resources within their area. Community activities, senior centers, senior services, gyms, and exercise programs can offer low-cost or even free classes and resources for low-income seniors.

Strengthening Chronic Care Management Programs

Chronic care management programs are uniquely designed to help connect patients with the care and services they need to be successful in navigating social determinants of health-related issues. While healthcare providers we might not be able to solve all patient problems, a chronic care management program that combines actively engaging patients, asking the right questions, and pursuing creative problem solving will go a long way in helping our patients live longer, healthier lives regardless of any chronic disease or SDoH challenge they may face.

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