How to Develop a Targeted Care Management Approach for Addressing Social Determinants of Health


This type of focused approach incorporates four key steps.

As any experienced care manager can attest, there is nothing new about “social determinants of health.” The term refers to various social, economic, and environmental factors that can impact a person’s health and risk of disease, including poverty, unstable housing, high-stress life events (e.g., death of a spouse or child, moving), and a lack of social support. Unfortunately, these factors have troubled societies since the earliest times, and care managers deal with these challenges every day as they try to help individuals better manage their health.

What is new-and welcomed-is the growing commitment among healthcare leaders to double down on social determinants of health. Decades of social epidemiology research shows that these factors can significantly increase a person’s risk of disease, including heart attack and stroke, as well as common infections like the flu. In fact, social, economic, and environmental issues have been shown to influence the length and quality of life by 50%, according to community health research. In comparison, only 20% is tied to the clinical care provided to community residents.

If approached in the right way, health plans can significantly improve population health outcomes and reduce overall costs by helping members address non-medical challenges such as social determinants of health. These factors cause chronic stress, which biologically increases disease risk and may compromise a member’s ability to adopt healthy behaviors. Plus, some social determinants of health, such as lack of transportation or low health literacy, directly interfere with a member’s ability to engage in preventive and condition management care.

What is the “right” way for health plans to address social determinants of health? Care management is only successful if the member is engaged and activated, or willing and able to work with the care manager. Health plans that use a targeted, relationship-oriented approach, focused on helping at-risk members address one social determinant at a time, can yield engagement and retention rates as high as 25% and 50%, respectively, compared to the industry average of 10% to 20%.

This type of focused approach incorporates the following four key steps:

  • Pinpoint members at future risk of a medical event. Traditional risk stratification models focus on sorting through claims data to identify high-risk members who use a lot of medical resources. In other words, they pinpoint members after they experience a high-cost medical event. In contrast, newer stratification models predict which members are at risk of experiencing a medical event, such as being hospitalized in the near future, due to an unmanaged chronic disease combined with high levels of social stress. By widening the panel of members who are eligible for care management to include these at-risk individuals, health plans can prevent disease progression and complications and lower overall costs.
  • Look at social determinants of health. Sophisticated predictive analytical models can also pinpoint which at-risk members are struggling with social determinants of health that may be interfering with their ability to take care of themselves. In addition to looking at claims data to uncover clinical clues of physical health changes (e.g., diagnosis codes, recent prescriptions), these models mine other types of data, including marketing and U.S. Census data, for socioeconomic and environmental clues. For instance, the data may reveal that a member is in debt, lives alone, or lacks transportation. 

However, not all social determinants of health can or should be addressed through care management. For instance, research shows that individuals with less education tend to have poorer health outcomes than those with more education. A care manager cannot change a member’s educational level. However, when members cannot earn above minimum wage due to a lack of education, then care managers might talk to those members about local training programs that can help them prepare for a higher-paying occupation.

  3. Make it easy for care managers to know what to focus on. One way to help care managers use their time efficiently is to help them target their interactions with members around a specific issue uncovered via predictive analytics. For instance, if the modeling identifies that a member with newly diagnosed heart failure was recently widowed and is living alone, that information could be auto-populated to help inform the care plan for that member.

In this way, care managers can contact members about a specific challenge they are experiencing, rather than to offer general assistance. This approach can also turn an analytical exercise into a real-life action plan. Customized recommendations can be automatically added to the care plan to correlate with the member’s medical and behavioral health history and any identified social determinants of health. Then the care manager can refer to and verify these care barriers when reaching out to a member. 

For example, an initial phone contact might go like this: “It looks like you’re having trouble filling your prescriptions. There may be some financial challenges that are making it hard for you to pay for your medications. If it would be helpful, I can connect you to some resources that can assist with your medication costs.”

  4. Engage members with high-touch support.Targeted care management approaches likely increase member engagement for a number of reasons. One is that members who are challenged by various social, economic, and environmental issues are often overwhelmed. When care managers reach out to members with specific and appropriate solutions to problems they may have been struggling with for a long time, the members likely feel a combination of relief and gratitude.

Members with complex needs, including social, economic, and environmental challenges, often respond best to a one-on-one, clinical and social approach that may include telephonic, text, and in-person care management support. However, the first step in building a trusting and effective relationship between the care manager and member is to pinpoint how best to help the member.

Virginia Gurley, MD, MPH, is the chief medical officer at AxisPoint Health, responsible for leading all clinical content management activities, shaping the direction of the company’s analytics offerings, and providing strategic clinical oversight for delivery of population health management services. Gurley brings with her more than 30 years of experience in preventive medicine, clinical systems design, health services research, and health education.

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