Social determinants of health have a substantial impact on the health outcomes of patients. Medical facilities must recognize and adapt to SDOH demands if they want to achieve health equity for individuals from all demographic groups. This holds true for all practices but is particularly relevant for patients who are in high need like those who have a disability, low income, older or suffer from multiple chronic diseases.

Programs such as Chronic care management are well-positioned to manage SDOH concerns because of their consistent ongoing care. Because of this program, the health care providers can stay in check with the patients regularly and they can consider patients’ ongoing needs rather than emergencies. CCM can assist practices in addressing SDH and working for health equity for all patients by providing monthly check-ins, care plan goals, and assistance in navigating the available community resources.

Social Determinants of Health

The non-medical factors that have an impact on the health of a population are considered the social determinants of health (SDOH). These are the situations where people learn, work, progress, live, and get older as well as the systems and factors that shape day-to-day living circumstances. These systems and factors include development agendas, social policies, social norms, economic policies, and systems.

The SDOH plays a significant role in the distribution of health-related disparities – the preventable differences in health observed within and between societies. In countries at all levels of income, health and illness follow a social gradient: the poorer the socio-economic status, the poorer the health.

There is a list of all the social health determinants that have both positive and negative effects on health:

Addressing SDOH Through Chronic Care Management (CCM)

Every healthcare practice would like to assess patients for SDOH but they do not have the time to do so, particularly when they are operating on limited staff. Chronic care management programs, for example, employ care coordinators who have tools to assess patient’s SDOH needs and direct them to relevant services.

CCM is a highly engaging program that offers several opportunities to interact with the physician so that the healthcare providers can assist the patients in understanding the necessary prerequisites for a successful chronic care management program with better health results. This goal is achieved through the use of digital health platforms and cellular technology, including patient portals and RPM devices that allow doctors to communicate with their patients beyond the clinic.

CCM team-based approach has a framework in which care coordinators, social workers, and healthcare specialists work together to address different factors that impact the health of a patient.

Regardless of all the SDOH challenges and chronic illness that patients are facing, the chronic care management program actively involves patients asks them relevant questions and then looks for creative problem-solving solutions that can help them in a long way in improving their lifestyle for better health outcomes.

Enhancing SDOH Integration Through the Chronic Care Management (CCM) Program

With a smooth connection between patients with chronic illnesses and healthcare resources, Chronic Care Management (CCM) programs are essential in addressing Social Determinants of Health (SDOH). They offer a structured framework that fills the gap between care coordination and resource limitations while also producing additional benefits:

1. Screening and Evaluation

CCM programs conduct thorough patient screenings, considering SDOH factors like food security, housing stability, and transportation access.

CCM programs conduct thorough patient screenings, considering SDOH factors like food security, housing stability, and transportation access.

2. Customized Care Plans

Based on screening results, CCM mandates individualized care plans for each patient.

Providers update these plans monthly, documenting changes and interventions to improve health outcomes.

3. Community Connections

CCM care teams facilitate connections to community resources and SDOH-related support services.

Referrals may include social workers, housing assistance, or transportation programs.

4. Patient Education and Support

Patients actively engage in managing chronic diseases through regular communication with physicians.

CCM programs address SDOH-related challenges during remote interactions.

5. Medication Management

CCM helps patients obtain new prescriptions and monitors medication adherence as part of the treatment plan.

Advancing Health Equity Through Chronic Care Management (CCM)

Community Health Centers, FQHCs, RHCs, and other clinics in rural or low-income areas are essential for improving health equity and serving the uninsured and underinsured patients. To assist these organizations, CMS reimburses CCM at higher rates for FQHCs and RHCs than other healthcare facilities.

RHCs, FQHCs, and similar practices treat populations that often face fluctuations financially and other SDOH factors. Such patients may reside in areas where they face poor access to healthy foods also known as the food desert. They may also work multiple jobs, not own a car or live far away from a healthcare facility, all of which make it challenging to attend routine appointments.

Since CCM provides access to SDOH resources and encompasses distant preventative care, it is in a position to target the requirements of rural and low-income sufferers, including RHC and FQHC.

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