Addressing Social Determinants of Health (SDOH) Using Chronic Care Management (CCM)

When it comes to good health, there are many lifestyle choices that impact your overall wellness in the long run. Right from education to wholesome food and secure housing to environmental factors and social support systems to family, there are many aspects that determine your health, wellness, and happiness. Social Determinants of Health (SDOH) is the term used to describe these aspects or elements that are responsible for having a substantial influence on an individual’s health outcomes.

What Includes Social Determinants of Health?

The term “SDOH” is relatively new in the medical field and is defined as the conditions under which individuals are born, grow, live, work, and age by the World Health Organization (WHO). Also known as medical social determinants of health, these conditions impact access to and the quality of medical care an individual receives, along with affecting the health outcomes for the most vulnerable population.

A clinician can readily understand and address these challenges when administering treatment after taking into account, the patient’s age, living conditions, household environment, and level of education.

The Institute of Medicine (IOM) recommends that the social and behavioral health domains must be captured for individuals who are at an increased risk for health conditions and face barriers to receiving quality medical care.

The following must be considered in regard to SDOH:

• Prioritization: An assessment must be conducted to ensure readiness to implement proven techniques that are critical to determining which patients will benefit the most, and which SDOHs will have the biggest influence on the overall population and healthcare expenditures.
• Non-medical Factors: A medical approach to non-medical factors will result in better healthcare services rather than focusing on cost-effective and community-based alternatives.
• Data Collection: A physician must decide why and which data is being collected, check out its comprehensiveness, calculate the proportion of people involved, discuss the data’s intended use, and consider standardizing the data.
• Forming Partnerships: Establishing multisector collaborations necessitates confidence to share data, funds, and other resources. Building trust amongst government agencies, community partners, and healthcare organizations plays a crucial role.

What, When & How To Address SDOH?

The impact of social determinants of health, such as an older population living longer, is causing us to face ever-increasingly poor health outcomes. Healthcare systems and clinicians can take certain steps to address some of the SDOH issues, even without a systematized approach.

Inquiries about the patient’s living conditions, access to transportation, having visitors, and difficulties taking prescribed medications must be discussed during a consultation. This data can help determine the possibility that a patient would experience a medical emergency or develop behavioral disorders like sadness or anxiety.

In other words, to effectively address the social determinants of health, a comprehensive strategy that takes into account the various elements that influence health outcomes—such as social support networks, access to healthcare, and policies and practices that affect living and working conditions—is needed.

Addressing SDOH Using Chronic Care Management

There is a demand for healthcare organizations to establish connections with chronically ill patients in their communities, at work, at local grocery stores, and at educational institutions, in addition to the hospital sites or clinics.

Chronic Care Management (CCM) programs have become an effective means of addressing social determinants and enhancing the quality of life for those who suffer from long-term medical illnesses. This patient-centered method of healthcare delivery emphasizes coordinated care and an all-encompassing treatment approach that considers various aspects that affect a person’s health and well-being.

Since CCM is highly interactive and provides multiple opportunities for patient-physician interactions, healthcare providers can help patients determine the specific requirements needed to succeed in their chronic care management program with better health outcomes. This goal is accomplished by using digital health platforms and cellular technology, such as patient portals and remote patient monitoring (RPM) devices that enable doctors to stay in touch with their patients outside of the clinic.

Healthcare providers such as social workers, care coordinators, and other specialists can collaborate to address various aspects that affect a patient’s health in the context of CCM’s team-based approach to care coordination.

Regardless of the chronic illness or SDOH challenges patients are facing, a chronic care management program actively incorporates them, asks the relevant questions, and seeks innovative problem-solving solutions that go a long way in helping them live longer and healthier lives.

How CCM Program Strengthen SDOH Integration?

Chronic Care Management (CCM) programs play a vital role in addressing Social Determinants of Health (SDOH) with a seamless connection between chronically ill patients and healthcare resources. These programs provide a well-organized framework that not only closes the gap between resource constraints and care coordination but also yields other advantages:

• Evaluations and screening

Comprehensive patient screening, including a range of SDOH elements such as food security, stable housing, and ease of access to transportation, is carried out by CCM programs. These evaluations provide insightful information that enables healthcare providers to identify patients dealing with particular SDOH issues.

• Customized care programs

Based on the risk factors identified during screenings, CCM mandates that each patient have a specific care plan that is developed and implemented to deliver better health outcomes. CMS guidelines require providers to update these care plans after monthly evaluation of patients, documenting changes, improvements or interventions needed on patients’ specific health conditions. These plans help patients achieve better overall well-being by addressing social and economic issues that impact health and medical concerns.

• Community connections

CCM care teams are focused on helping patients make connections with community resources and SDOH-related support services to overcome obstacles in their wellness journey. This may include making referrals to social workers, neighborhood associations, housing assistance programs, or transportation services.

• Patient education and support

Patients can undertake an active role in their wellness program by learning how to manage their chronic diseases through CCM programs that promote proactive and continuous communication with patients. A physician can better understand patients’ needs and preferences and discuss how to manage SDOH-related challenges through this regular remote interaction.

• Managing medication usage

The capacity of a patient to follow their prescription regimen can be impacted by SDOH elements. CCM programs help patients get new prescriptions and even track how well they take their medications as stated under the treatment plan.

How HealthArc Can Help Address Social Determinants of Health?

To assist physicians and clinicians in addressing the Social Determinants of Health (SDOH) for their patients, HealthArc provides a comprehensive Chronic Care Management program and clinical software that’s formulated to meet coordinated care objectives. Healthcare providers can recognize and respond to SDOH-related issues that could impact a patient’s condition by staying in constant contact with their CCM patients on our platform.

Using our CCM system, physicians can address SDOH variables and close care gaps that eventually improve patient outcomes in the long run.

Strengthen Chronic Care Management Programs With HealthArc 

Our CCM programs are designed to help connect patients with the care services they need to navigate social determinants regarding health-related issues by actively engaging patients.

You can put a thorough CCM program in place that complements your patients’ treatment plans and generated additional income for your practice. You may enable your CCM patients to better manage their chronic conditions and potential SDOH issues, by utilizing our digital health platform.

Get in touch with us right now at +201 885 5571 to learn more about our CCM services or request a free demo now.