July 13, 2022

7 min read

Overcoming Social Determinants With Chronic Care Management Solutions

Part one in a two-part series

It's been well-documented that social determinants impact the health and wellness of patients in numerous ways, but how do we more effectively address those issues that impact patients negatively? One path provider organizations are increasingly taking to help them overcome social determinants of health (SDoH) challenges is through the addition of chronic care management solutions.

A compelling reason to leverage CCM (chronic care management) solutions is to help the most vulnerable patients, which undoubtedly includes those faced with SDoH challenges. We know that CCM, especially when included in a broader comprehensive care management program, helps get patients timelier and more efficient care while also being financially lucrative for providers. Preventive care and enhanced care management saves money and provides many more years of wellness.

However, social determinants of health can make achieving these goals more difficult for many Americans. How do we better reach and support those patients who are experiencing some of the most profound impacts of SDoH? Chronic care management solutions, including software platforms that help organizations streamline the provision of CCM services, are proving to be some of the most effective mechanisms.

In this first in a two-part series, we'll briefly review the concept of social determinants of health and some of the most impactful social determinants. We'll then look at how chronic care management solutions can help organizations better navigate SDoH.

Real Impact of Social Determinants of Health

To more effectively address this question, we should first gain a better understanding of social determinants of health. According to the CDC, SDoH is defined as "conditions in the places where people learn, work and play that affect a wide range of health and quality-of life-risks and outcomes."

Simply put, social determinants are the non-medical factors — positive and negative — that influence health risks and outcomes. When SDoH contribute to health inequities, patients can find it more difficult to access and receive the care and services intended to improve their health and wellness. The most common and impactful social determinants of health fall into four categories, with each playing a significant role in the lives of patients.


Where someone lives has a noteworthy influence on their ability to access day-to-day needs, thus impacting many areas of their life. Location can affect everything from ability to earn money, ability to locate and afford safe housing, level of education, public safety, and access to basic and essential healthcare services. Patients who live in rural or financially depressed areas often experience the most severe chronic health conditions and suffer significant adverse health outcomes simply because of where they call home. While these people would benefit from participation in regular, in-person preventive care, their location often creates a barrier for them to do so consistently. Fortunately, as will be discussed below, chronic care management solutions that help with the provision of virtual services can help reduce the impact of such an SDoH barrier.


Those without a steady source of income or who rely on a low income often struggle to secure the most basic needs like food and shelter. If one can't afford to eat, then they most likely believe they will be priced out of accessing quality healthcare services. Furthermore, many low-income patients delay care by skipping doctors' appointments due to concerns about out-of-pocket costs or avoid maintaining adherence to medication regimens because prescriptions seem difficult or impossible to afford. These problems can have a compounding effect, creating worsening or even deadly chronic disease outcomes. Fortunately, chronic care management can be the cost-effective services that help patients receive the care they need without further straining their tight budgets.


We now know that there is a direct correlation between one's level of education and level of health literacy. The American Academy of Family Physicians found most American adults only read at an eighth-grade level and a staggering 20% of U.S. adults read below a fifth-grade level. Since healthcare educational materials are typically written at a tenth-grade level, most adults might not fully understand their health, diagnosis, prognosis, recommendations, and options, such as chronic care management. Health literacy can be a significant barrier to access care and achieve positive health outcomes.

Housing security

Housing security can be described as access to a safe and permanent place to live. Housing plays a direct role in health and wellness because without a safe place to live, it is difficult to adopt healthy behaviors, maintain health, or effectively manage chronic health conditions. Every day, hospitals release patients back into the world, but many of these people will be readmitted with failing health again and again simply because they do not have safe, secure, and sanitary place to recover from an illness or injury. Furthermore, without housing, patients have no place to practice and maintain good health habits, making the emergency room entrance an all-too-frequent and expensive revolving door.

Navigating Negative Social Determinants Through Chronic Care Management Solutions

Just because our patients may be facing social determinants of health challenges doesn't mean we can't design effective chronic care management models that can meet these patients where they are and in the situation they find themselves in. Patients are most successful when they are actively engaged and willing to do the work required to improve their health and wellness, but if they are facing social barriers like those discussed above, they will likely have their attention focused elsewhere and place their health and wellness on the back burner. Supporting our patients — no matter where they land on the socioeconomic status bar — is how we achieve better health outcomes while helping to address the out-of-control costs associated with chronic diseases.

Social determinants are nothing new. Being creative in addressing those barriers is key. That's why it's imperative that the chronic care management solutions an organization uses take into consideration the most common barriers that its patient population will face.

Within CMS's chronic care management requirements, practitioners and their care teams should be taking into consideration and addressing their individual patient's social determinants of health. A vital aspect of the chronic care management model is to help identify any outside barriers that could be interrupting the patient's path to better health and wellness. Providing a combination of support, encouragement, and connections to community housing resources, job training programs, senior services, communication resources, food services, and even transportation resources can help the patient overcome some of their most substantial SDoH barriers. If patients are concerned about their chronic care management costs, have a discussion about the value of their investment in CCM. Chronic care management requires strong patient engagement. Such a conversation, including options for enrollment assistance, can help secure the necessary buy-in.

Internally, organizations offering CCM can better ensure the chronic care management tools and resources that help engage patients are easily accessible, with written materials produced at no higher than a fifth grade reading level. Furthermore, chronic care management is best leveraged when organizations offer remote and telehealth options to receive CCM services, thus decreasing barriers like transportation access, cost, and the time needed to receive care.

Combining CCM with other care management services like remote patient monitoring (RPM) and behavioral health integration (BH) as part of a broader comprehensive care management program can prove greatly beneficial for patients encountering SDoH barriers. Consider the benefits of including RPM in such a program for rural patients. As Thea Blystone, PharmD, a clinical pharmacist at Meadville (Pa.) Medical Center states, "RPM services are a great fit for rural hospitals. RPM gives the providers 'eyes' on the patients between office visits and greatly helps to personalize medication regimens for each patient through the ongoing collection of data..." Well-designed CCM solutions can help organizations build and grow a comprehensive program.

CCM solutions should also serve to help care team members catch SDoH challenges. When discovered, these team members can then collaborate closely with community resources and payers, working as advocates for patients. For example, if a patient is having trouble getting to the pharmacy to pick up prescriptions and therefore missing or skipping doses, care team members could work with patients to have their medications delivered through a mail order program. Patients don't always know what help is available to them, and sometimes they need a little handholding and encouragement to ensure maximizing of the value of CCM.

Chronic Care Management Solutions as Difference Makers

Social determinants of health will always affect the way people live and their ability to access the healthcare services they need. We have a great opportunity through offerings like CCM to play an active role in supporting some of our most vulnerable patients. Chronic care solutions that help organizations not only deliver CCM but also other care management services provide the means to better meet patients where they are, helping them more effectively navigate SDoH barriers so they can achieve the highest level of health and wellness possible.

While this is good news on its own, there's even more good news for organizations with or considering adding CCM solutions. The "love" being shown by CMS for chronic care management models makes adding such services financially worthwhile while those with value-based contracts will see CCM help reduce readmissions and other expenses by keeping patients healthier and out of the emergency room. Chronic care management truly is a difference maker for patients, organizations, and our healthcare system as a whole.

In part two of this two-part series, we'll further explore common social determinants of health situations and discuss how chronic care management can help identify and manage these issues.

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