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Contributor: How Chronic Care Management Could Be the Great Equalizer for Care


By creating a framework for social determinants of health that explores patients’ needs and prioritizes team members’ response, specialty practices can more effectively strengthen health equity, access to care, and health outcomes.

Social determinants of health (SDOH) have a tremendous impact on care outcomes for patients with chronic and complex disease. However, uncovering the factors that could influence outcomes—from food insecurity to health literacy to access to reliable transportation—can be challenging for specialty practices.

Researchers believe SDOH could affect 80% of health outcomes. That’s especially concerning given that recent data indicate a large proportion of adults are experiencing hardship during the COVID-19 pandemic, from economic hardship to symptoms of anxiety or depression. Adults in households with children are “more likely to report food insufficiency, symptoms of depression or anxiety, and no confidence in [their] ability to make next month’s housing payment.” Other populations that face higher risk include Black and Hispanic adults and adults 43 years and younger.

For specialty practices, the opportunity to make a significant difference in SDOH is exciting—but it can also feel intimidating. Screenings for breast cancer, colon cancer, cervical cancer, and more plunged during the pandemic. Now, experts predict a surge in patients presenting with advanced cancer, something many specialty practices already are seeing. This raises numerous practical concerns for specialty practices, including:

  • How can we touch more patients—even when we don’t see them face to face?
  • How can we ensure that care navigators and medical assistants properly triage patients when they call with concerns about their health?

A systematic approach to identifying and responding to SDOH—developed as part of a chronic care management (CCM) program—can become “the great equalizer in care” by helping to address these challenges. Such an approach empowers care navigators and medical assistants to act as “extenders” for specialty care practices, making connections that uncover health risks and social needs. In doing so, it supports reliable access to care resources and community services for those who need them most.

Creating the right framework for SDOH identification and response is key. Here are 3 key elements to consider.

  1. Navigating discussions around tools for SDOH. Provide a clinical framework for team members to initiate discussions with patients without using buzzwords like “food insecurity.” For instance, in my work at Genesis Healthcare Partners, PC, a urology practice, we found that while good nutrition is an important part of cancer care, discussions around diet, nutrition, and exercise were not taking place as often as we would have liked. Now, care navigators and medical assistants make sure to ask: “What are you eating these days? Are you getting around much? How do you enjoy staying active?” Based on these answers, these professionals can dig deeper, looking for red flags such as unexplained weight loss that can point to the need for an in-person visit or physician follow-up.

    Establishing trust and care rapport is key. Sometimes, simply having another professional on the team ask these questions can lead to more robust discussions around SDOH. Other times, asking questions in a different way or in a different tone of voice may be most effective.

    A tip: Provide condition-specific questions that can help uncover and/or combat the common SDOH gap of health literacy. For instance, a patient who is recovering from treatment for an in-office benign prostatic hyperplasia procedure should understand: “Are you seeing blood in your urine? Are you urinating more frequently? Immediately after the procedure, these symptoms are normal. Are you having pain in your back with urinating? This could be a sign of a complication.” By breaking questions down at a level the patient understands or is likely to respond to, specialty practices can more easily navigate discussions around SDOH for better outcomes.
  2. Prioritizing which patients are escalated for in-person follow-up care—and when. A framework for prioritizing which patients to speak with as well as when and how to escalate patients for follow-up care ensures that clinicians work within their scope of care. It also gives clinicians greater confidence in embarking on questions around SDOH and other risk factors, knowing that they have the tools to properly identify patients who need additional support and bring them to the physician’s attention.

    Increasingly, specialty practices rely on software with condition-specific clinical questions and protocols to assist care navigators and medical assistants in determining next steps in care. The right software solution will translate disease-specific clinical protocols into straightforward care pathways for staff to follow. Leading solutions combine proven clinical protocols with artificial intelligence to ensure the right treatment is provided safer, faster, and with better outcomes.
  3. Establishing a forum for sharing lessons learned in SDOH discovery and response. An option: Bring care navigators, medical assistants, and key providers together once a week to share tips for initiating organic discussions around SDOH with patients and building higher levels of trust. The types of conversations we are having in my practice include reflections such as, “With engineering-minded patients, this approach tends to work best,” or “When you have a patient who wants to hang up right away, try this approach.” Some patients prefer discussions that are more technically oriented; others simply want to feel understood. Meeting patients where they are is key to success in assessing and responding to SDOH, but it takes patience and skill to get there. Team members should seek to understand not just a patient’s health risks and status, but also their goals for treatment. A patient with prostate cancer whose cancer has progressed, for example, might be just as interested in his sexual health as he is in learning about his disease spreading.

By creating a framework for SDOH discovery and response that explores patients’ needs and prioritizes team members’ response, specialty practices can more effectively strengthen health equity, access to care, and health outcomes in a rising-risk environment.

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