Social determinants of health (SDOH) continue to gain attention as the factors that weigh heavily on physical and mental health. This was particularly evident during the COVID-19 pandemic when the hardest impact was felt by minority and underserved individuals and communities (Abrams & Szefler, 2020; World Health Organization [WHO], 2021). As WHO (2021) stated, "COVID-19 infection, hospitalization and mortality have been grossly unequal between population groups-driven by inequalities in the social determinants of health" (p. 4). Although the spotlight is deservedly focused on the importance of understanding SDOH in the context of health care today, these factors are not new. As an area of study, they date back decades (Osmick & Wilson, 2020) and, as a fact of life, they go back centuries. In response, professional case managers need 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.
WHO (2021) defines SDOH as:
The conditions in which people are born, grow, work, live, and age and people's access to power, money and resources. The social determinants are the major drivers of health inequities-unfair, avoidable and remediable differences in health between social groups. (p. 6)
The U.S. Department of Health and Human Services (HHS) describes SDOH as "the conditions in the environments where people are born, live, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks" (HHS, n.d.-a). As these definitions show, SDOH spans multiple factors, often interconnected and deeply rooted in social structures, including generational poverty and its devastating impact on children (Aizer, 2017). Greater awareness of SDOH has prompted increased calls for action to address social and health inequalities. Such remediation includes addressing inequities in health care access resulting from, as the Population Health Alliance states, "many decades of social injustice in our population" (Osmick, 2021, p. 10). Osmick (2021) further observes that an integrated response is needed that spans health care, public policy, education, academics, businesses, and community organizations.
Without question, case management practice 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. For example, HHS's Healthy People initiative observes that approximately 10% of people in the United States are uninsured, which makes them less likely to have a primary care provider and more likely to struggle to pay for health care services and medications. 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 (HHS, n.d.-b).
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.
This article examines SDOH from the perspective of case management practice, based on both experiences of case managers in multiple care settings and drawing from recent research. It will show how embedding greater awareness of SDOH into the case management process-from intake and assessment through implementation, evaluation, and across care transitions-can establish rapport with clients of case management services (known as "patients" in some care settings) and support improved outcomes through best practices in care coordination. Doing so, however, can be challenging, given today's increasing caseloads for case managers and the push to decrease the length of stay in acute care settings (Siddique et al., 2021) and overarching goals to decrease costs of care. Despite these competing priorities, case managers must advocate for clients beyond any specific episode of care, especially for high-risk individuals who are often most affected by SDOH. With greater awareness and a care coordination approach, professional case managers can identify and address SDOH and improve the health and well-being of people and populations.
SDOH and the Triple Aim
For more than a decade, the Triple Aim has been utilized across health care as a compelling vision of increasing the quality and outcomes of care in the United States, by improving the individual's experience of care, improving the health of populations, and reducing per capita costs of care (Berwick et al., 2008). The Code of Professional Conduct for Case Managers (the "Code"), published by the Commission for Case Manager Certification (CCMC), utilizes the Triple Aim as an overarching goal for the practice of case management, specifically to use "communication and available resources to promote health, quality, and cost-effective outcomes in support of the 'Triple Aim'..." (CCMC, 2015, p. 3). Thus, although case management takes an inherently individualized approach in assessing the needs of individuals and providing the right care and treatment at the right time and at the right cost, it is acknowledged that such actions can also contribute to the health of populations and better cost-effectiveness of care.
SDOH and inequitable access to care resources are among the biggest impediments to improving the health of individuals and populations. Such gaps have long existed. For example, the 1984 report submitted to the U.S. Congress from then-Secretary of Health and Human Services Margaret Heckler (1984), titled "Report of the Secretary's Task Force on Black & Minority Health," catalogued multiple disparities in health that had already existed among underserved groups, including higher death rates, delayed and less frequent access to care, and the impact of language, cultural differences, socioeconomic, and other factors. As the report stated:
Differing patterns of health services' utilization, health insurance coverage, access to health providers, and the availability of appropriate health education materials and programs contribute to the disparity in health status between minority and nonminority groups. Further study and identification of specific ways to improve minority access to each of these health resources is essential to improving the health status of minority groups in the United States. (p. 194)
Since the release of this report, ongoing research has continued to investigate the extent of SDOH and their impact. The COVID-19 pandemic once again exposed the impact of inequity on the health of many minority and underserved individuals and populations who have been found to be at greater risk of becoming sick and dying from COVID-19 than the overall population (Centers for Disease Control and Prevention, 2022). Case managers on the front lines of the pandemic response, particularly in urban areas, witnessed the overweighted impact of the pandemic on poor, homeless, and other underserved individuals. At the same time, case management values such as advocacy, autonomy, justice, and the client's right to self-determination compel case managers to help ensure fairness and equity for all individuals (Baker et al., 2021). This lesson, learned from COVID-19, informs the importance of applying case management principles and best practices to address SDOH in all care settings, from acute care to community-based settings and even workers' compensation. Otherwise, SDOH will continue to erect barriers to achieving the goals and vision of the Triple Aim. Screening for SDOH as part of the case management process, however, could promote both efficacy and cost-effectiveness. As risk factors that undermine an individual's health are identified, interventions can be put in place to support the individual's health goals and decrease unnecessary emergency department visits and hospitalizations.
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. 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.
"Paul" was an insulin-dependent diabetic and frequent user of the emergency department and other hospital services. Although he had access to insulin and was able to inject himself, every few months Paul came to the hospital in diabetic crisis and needed to be stabilized. Each time, the staff spoke with Paul to ensure he understood his condition, regularly monitored his blood glucose levels, and injected himself daily, all of which he confirmed. But when Paul brought himself to the hospital again, this time in a more fragile condition, the case manager and the diabetes educator decided they needed to dig more deeply by engaging in motivational interviewing. They began a conversation with Paul to find out more about his daily self-care, from how often he tested himself to where he stored his insulin that had to be refrigerated. That's when Paul finally disclosed that he lived out of his truck.
To refrigerate his insulin, he arranged with his sister to store his supplies in a refrigerator in her garage. His sister's husband had a conflict with Paul and would not let him into the house; hence, access to the garage refrigerator was the only way his sister could help him. When the diabetes educator asked him about his daily dosing, Paul finally admitted that he could not read the small numbers on the insulin syringes. Afraid of accidentally overdosing, he decided to intentionally underdose himself as a margin of safety. The cause of Paul's failing eyesight was diabetic retinopathy, which also needed to be addressed. But in the short term, a pair of nonprescription reading glasses, given to Paul by the diabetes educator, allowed him to see the numbers on the syringe and correctly dose himself. Going forward, the hospital investigated whether Paul could be prescribed injection devices known as insulin pens that would allow him to count the "clicks" to ensure the proper dosage.
Paul's health was clearly impacted by SDOH, including being undomiciled and economically disadvantaged and having a serious medical condition. Those details of his life, however, were unknown until the case manager and the diabetes educator established rapport with him. The issue was not a lack of understanding on his part, as repeating instructions each time Paul came to the hospital did nothing to keep him out of diabetic crisis. Any assumption that Paul was simply noncompliant had to be suspended. The case manager had to keep an open mind when engaging Paul about how he was managing his diabetes and overall health.
Motivational Interviewing and SDOH
As part of case management practice, motivational interviewing is a highly effective engagement technique, enabling the case manager to gather accurate and more thorough information. Using motivating interviewing, with open-ended questions, case managers can more readily uncover the health, environmental, social, and other needs and factors impacting their clients. The result is often greater rapport and a deeper, trusting relationship with the client in pursuit of the individual's goals (Tahan & Sminkey, 2012).
Motivational interviewing techniques of asking open-ended questions-for example, where do you store your insulin, how often do you test yourself-were crucial to engaging Paul in a conversation. Only by taking the time to discover more about his living conditions and challenges could the case manager and the diabetes instructor give him the support he needed to reach his goals of stabilizing his diabetes.
Such scenarios may be familiar to many case managers, particularly those who have worked in acute care and community-based settings in urban areas. One case manager described using gentle humor to engage a client who came to the emergency department repeatedly. "What, you miss me?" she asked with a smile. The client laughed, shook his head, and then described being underemployed, financially insecure, and living in a one-bedroom apartment with several adults who were not family members. He admitted to coming to the hospital on occasion to receive the care and rest he needed to manage a chronic health condition.
Such stories are reminders that professional case managers regularly encounter individuals whose health is undermined by SDOH. In the case of some individuals, SDOH may appear obvious, such as the individual who is uninsured and admits to choosing between paying for food, rent, or medications. For others, SDOH may be part of a silent shame they try to hide, such as the 40-year-old recently divorced single parent who had lost her job and struggled to pay her mortgage and bills and afford her medication. Based on her appearance and her residential address, no one could guess that she was negatively affected by SDOH. There was nothing in her medical record to indicate a sudden change in financial status; yet, the loss of her income and financial insecurity were directly impacting her health. Her situation only came to light when a case manager asked her, "How are you managing your self-care?"
Another example is an 80-year-old individual in assisted living, who told his doctors he only drank "socially." Unbeknownst to others, however, he had increased his alcohol consumption to several drinks daily. The impact on his health was undetected until he fell in the middle of the day and was found to have an elevated blood alcohol level. Social isolation and addiction, both SDOH, undermined his health and compromised his self-care. Yet, another example is the individual who worked two or more minimum wage jobs to support his family. After suffering a physical injury on one job, the individual did not report it, even though his care would have been covered by state-mandated workers' compensation. The reason was he wanted to continue working two jobs and receive a full wage from both. As a result, he "worked hurt," risking reinjury and the potential of permanent disability (Nunez et al., 2022).
As professional case managers engage with clients and build rapport through motivational interviewing, they can ask probing questions. Admittedly, this may be uncomfortable at first as it feels like prying into the client's personal life or into areas that are unrelated to their health. But starting with where the client is-for example, in a health crisis, not taking medications as prescribed, missing follow-up appointments with physicians and other care providers, not adhering to a prescribed diet-can open the door to deeper conversations. Such questions can provide the missing piece to reveal a more comprehensive and accurate picture of how this individual is being negatively impacted by SDOH.
Box 1 provides examples of motivational interviewing questions to probe SDOH.
For other case managers, encountering the negative impact of SDOH may be far less common, thus encouraging the assumption that few of their clients fall into this category. However, the lingering effects of the pandemic on mental health and addictions (National Institute on Drug Abuse, 2022); historic levels of inflation and rising cost of living; and the effects of aging and/or divorce and death of spouses/partners are among the contributing factors that fall under SDOH. As these conditions worsen, people's health status and their ability to access and afford treatment and care resources are impaired.
Uncovering underlying issues such as SDOH takes time, and the interactions needed to engage people in a safe and vulnerable conversation require a one-to-one approach. In acute care, the time needed for such interactions can be compromised by the priority to ensure hospital stays are kept as short as possible. When an individual is repeatedly in crisis, however, a person-centric case management approach must be deployed. The time invested in motivational interviewing is well worth it to uncover the factors undermining a person's health and compounding a disease condition.
Although case managers are in a unique position to identify SDOH as part of intake and assessment in the case management process, they share the responsibility with other members of the interdisciplinary care team. Each member of the care team-for example, the social worker, nurse, case manager, physician, respiratory or occupational therapist, nutritionist, or others-interacts with the client in somewhat different contexts. In addition, the individual may choose to share certain information with specific members of the team. As the team comes together, a fuller picture of the person's life and health is revealed, including how SDOH undermine the person's health and wellness.
Extending the Reach of Care Coordination
As this discussion shows, improving the health and well-being of individuals affected by SDOH requires a robust approach that extends beyond the walls or context of a care setting. All too often, people live in environments with significant gaps in access to health care, social support, nutrition, and other resources. The most insidious of the underlying factors is poverty and the impact of poor environments on health and wellness. Marcella Wilson, PhD, founder and chief executive officer of Transitions to Success, advocates for the development of a collaborative care model to address the negative effects of poverty on health. Her approach is a system of care that seeks to change the understanding of and treatment response to poverty. It is predicated on the understanding that poverty is neither a choice nor a character flaw but is an environmentally based condition (Wilson, 2021). Living in poverty brings with it exposure to poverty-related health risks, such as unhealthy air and water and other toxins. For such reasons, Wilson advocates responding to poverty with evidence-based standards of care that include care management, to coordinate resources effectively; financial literacy, to combat the risk of predatory lending practices; peer mentoring, modeled after 12-step programs, in which those who have experienced success offer mentoring to those who need help; and volunteerism, as a social, psychological, economic, and physical support (Wilson, 2021).
As one of the pillars in the Transitions to Success model, care management (or care coordination) illustrates the role of the professional case manager in serving the most vulnerable individuals and populations. Care coordination has been recognized as a priority for improving health care delivery and outcomes through interventions that include quality reporting, comprehensive and effective case management, and chronic disease management. Benefits achieved through care coordination include reduced hospital stays, lower cost of inpatient care, reduced usage of inpatient services, and higher satisfaction for individuals (Berry et al., 2013). Because of its comprehensive nature, care coordination is also being recognized as an effective strategy in identifying and addressing SDOH (Francis et al., 2018; Singer & Porta, 2022). For case managers, this is both an inspiration and a call to greater awareness and action.
Further evidence of the role of professional case managers in addressing SDOH can be inferred from the "The Future of Nursing 2020-2030" report, based on a study published by the National Academies of Science, Engineering and Medicine and sponsored by the Robert Wood Johnson Foundation. The report highlights what the authors saw as nurses' unique role in helping improve the health and well-being of individuals and populations, particularly to reduce health inequities. As the report states:
Nurses can address SDOH and help improve health equity by providing care management and team-based care; expanding the capacity of primary care, including maternal and pediatric care, mental health care, and telehealth; and providing care in school, home, work, and public health settings. (Wakefield et al., 2021, p. 7)
Although the report specifically addresses nurses, there are clear implications for case managers, the majority of whom have a professional background in nursing (Tahan et al., 2020). Specifically, the report's mention of care management speaks directly to case management practice, across professional disciplines, backgrounds, and care settings. Therefore, case managers can be guided by the report's vision of providing care management with "a holistic view of the patient's health and social needs, and close monitoring and follow-up of patients to address these issues" (Wakefield et al., 2021, p. 149).
Similarly, HHS's Healthy People initiative has set forth decade-long, measurable objectives to improve public health. The initiative puts increased attention on health equity, SDOH, and health literacy, with a new focus on well-being. Its overarching goals to be achieved by 2030 include attaining healthy life and well-being without preventable disease, disability, injury and premature death; elimination of health disparities and inequity and achievement of health literacy; creation of environments-social, physical, and economic-to promote health and well-being; and promotion of healthy development, behaviors, and well-being across the lifecycle (HHS, n.d.-b). The Healthy People initiative and its focus and goals are reflective of case management best practices. A key takeaway, once again, is the importance of care coordination and providing greater accessibility to health care and resources to improve health and well-being.
A Shift in Thinking
Case management responses to SDOH may require a shift in thinking, beyond a particular incident or episode of care to a bigger picture of the individual's health, socioeconomics, access to care, and other environmental factors. As discussed, professional case managers are well positioned to address SDOH through care coordination, which is a major function of case management practice. In addition, there are opportunities to identify new roles in care coordination. As care increasingly moves outside the walls of the hospital, care coordination must move with it. Having more case managers present in community and accountable care organizations will help identify SDOH. In addition, an increasingly integrated approach to care coordination, with case managers leading the charge to address both the physical and behavioral health needs of their clients, will improve not only the care of the individual but also the care of the population.
With these expanded responsibilities, case managers can exert more influence over interprofessional care teams across the continuum of health care. It starts with a more complete understanding of the client's circumstances and challenges. These insights allow professional case managers to do what they do best: engage in care coordination to identify available resources, including in the community, to meet the person's needs in the context of the reality of SDOH.
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