BY, MS, CCM, CVE, BCPA
In light of the racial and justice issues impacting the United States that have reverberated around the world, there is a growing awareness of the impact of racism and other forms of discriminatory actions impacting the health and safety of marginalized populations. The clients that case managers serve who are members of these populations have been dealing with these challenges in society for centuries. These inequities have been felt in healthcare, education, criminal justice and other systems in society. Case managers are becoming increasingly aware of terms such as health disparities, health equity, and diversity, equity and inclusion (DEI). The health and human services organizations that case managers work for are also gaining a growing awareness of the need to address the impact of health disparities on the ability to achieve health equity. Employers are recognizing that in order to have flourishing businesses that are responsive to the needs of customers and employees, they need to embrace DEI initiatives. Insurance carriers are also realizing the need to identify and address health disparities in order to improve health outcomes while also realizing cost savings.
DEFINING KEY TERMS
Health disparities result in adverse impacts on groups of people who experience barriers and gaps in care based on one or more demographics, such as race, ethnicity, gender, sexual orientation, socioeconomic status, disability status, language, gender identity, nationality, or other factors. These disparities are closely linked with social, economic and/or environmental disadvantage. They also result in increases in the incidence, severity and mortality rates of the affected people. Health disparities are inherently unjust and are compounded by systemic barriers to timely and effective, culturally competent healthcare services due to explicit and implicit discrimination as well as stigma.
In light of the challenges of health disparities, health equity has evolved by focusing on those barriers and gaps in care, such as coordinating timely access to culturally competent providers, increasing preventive screening rates, and improving adherence to chronic care guidelines. From a societal perspective, that requires addressing poverty, joblessness, homelessness and safety. At an individual case manager level, it requires case managers to identify potential and actual health disparities, so that interventions can be taken to eliminate the gaps and barriers in health and its determinants.
The social determinants of health (SDoH) are also closely connected to the challenges and opportunities. Inherent in SDoH are the economic and social conditions that impact the health of both people and communities. In order to effectively deliver case management services, case managers need to identify and address the social needs of their clients. This requires awareness, data, screening tools and effective interventions.
The case manager may address the SDoH needs of client by coordinating referrals for services in the home and community, such as:
- Preventing falls
- Facilitating access to healthy foods
- Coordinating access to transportation
- Reducing social isolation
- Addressing homelessness
- Identifying culturally competent providers
These kinds of interventions and services are particularly important for clients with complex health conditions and social risk factors who likely have significant functional limitations. These services can improve the health outcomes of these high-risk clients while reducing healthcare costs.
IDENTIFYING THE IMPORTANCE IN CASE MANAGEMENT PRACTICE
Licensed and certified case managers have codes of conduct (or similarly named documents) that govern professional conduct. The Case Management Society of America (CMSA®) has its Standards of Practice for Case Management, which includes guiding principles impacting health equity, such as cultural competency, cultural and linguistic sensitivity and knowledge of diverse populations. The ethics standards include, among other requirements, recognizing that all clients are unique individuals and to engage with clients without regard to gender identity, race or ethnicity, religion, cultural preferences or socioeconomic status. The standards go on to indicate that case managers are expected to recognize, prevent and eliminate disparities in accessing high-quality care.
Another example is from the Commission for Case Manager Certification® (CCMC®), which has a Code of Professional Conduct that includes underlying values for professional case management services such as recognizing the dignity, worth and rights of all people. The code also includes ethical principles that support health equity in case management practice, such as advocacy, which is the act of recommending and pleading the cause of another, as well as justice that involves the idea of fairness and equality in terms of access to resources and treatment by others.
DESCRIBING EFFECTIVE HEALTH EQUITY STRATEGIES IN CASE MANAGEMENT
Education – It is important that case managers educate themselves about health disparities and health equity. In addition, case managers need to develop cultural competency in working with a wide array of clients. This will require case managers to acquire the knowledge, skills and abilities to deliver case management services to clients with diverse values, beliefs and behaviors. This will also require case managers to assess and address the health (including physical and behavioral health), social, cultural and spiritual needs of clients.
Social Determinants of Health – Case managers can incorporate screening for SDoH into the assessment process. There are a variety of SDoH screening instruments available to case managers depending on the setting of services. The National Association of Community Health Centers has a Protocol to Responding to and Assessing Patients’ Assets, Risks, and Experiences Tool (PRAPARE) that includes 15 core questions and five supplemental questions. The Centers for Medicare & Medicaid Services Accountable Health Communities Health-Related Social Needs Screening Tool (AHC-HRSN) is meant to be self-administered.
Community Based Organizations (CBOs) – When a case manager detects a social risk, the case manager can provide navigation to community-based organizations to meet those needs. These organizations may not be familiar to some case managers working with in a healthcare system; however, the services they provide can help support clients in safely transitioning to the home or community. They can assist in providing free or discounted services not covered by insurance plans such as providing non-medical transportation, securing a communication device or computer, delivering nutritious meals, assistance in paying for utilities and securing a safe living situation.
Client-Centered Strategies – Case managers can use patient-centered shared decision making, which is a process that allows clients and their providers to make healthcare decisions together, taking into account the best scientific evidence available, as well as the client’s values and perceptions. This strategy is appropriate when the client is faced with treatments, screenings and management options and there is evidence for more than one option, including no treatment. This requires robust communication skills, so that informed consent and motivational interviewing can augment the process. Motivational interviewing is a counseling technique that helps clients identify and resolve ambivalent feelings and insecurities in order to lead to the internal motivation needed to change behavior through the use of practical and empathetic approaches.
Culturally Competent Providers – In order to meet the needs of marginalized clients, case managers need to know who the culturally competent providers are. This could be through self-attestation by providers, completion of training and certification programs and analysis of outcome data. Additionally, case managers can better support their clients from Black and Brown communities by getting access to the racial and ethnic demographics of healthcare providers, as well as gender and languages spoken.
Accommodations – Case managers may deal with a range of health conditions, including individuals with mobility, hearing, vision, cognitive and other types of impairments. Clients who are not English speakers may also be served by case managers. Case managers should be aware of resources to assist in accommodating the needs of their clients in order to facilitate accessible communication as well as identify accessible care settings.
Case managers have the opportunity to identify health disparities while striving to achieve health equity. The clients served by case managers may require attention to unjustifiable health disparities that case managers must recognize in order to fulfill the duty in meeting the five basic ethical principles in case management practice, including beneficence, non-maleficence, autonomy, justice and fidelity. This requires case managers to acquire the knowledge, skills and ability to better serve clients.
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