Can Tracking Social Determinants Of Health Improve A Case Manager’s Chronic Care Management Plan?



To make man whole.1 Pause, just for a moment, and think about what this means. It could be an alternative interpretation of a case manager’s role in the care of their chronically ill patients. In this article, we explore how this parallelism offers a second topic for consideration that may impact your patients’ care, social determinants of health (SDOH).

SDOH have begun to reclaim the spotlight within patient care, which may very well be an effect of the COVID-19 crisis. Patients experienced unexpected and involuntary isolation, forcing a peculiar silver lining: The healthcare community had to find new ways to provide consistent care to their chronically ill patients, and subsequently SDOH needs are being incorporated into the whole-person care model.

Let’s begin with the most recent definition by the CDC. The CDC2 reports that quality of life, health risks and nearly all environments that impact our lives affect our health. This is a much broader interpretation than previous definitions, which were focused on static elements such as socioeconomic status, zip codes and education. More recently the definition has been expanded beyond what occurs in the doctor’s office. In other words, all aspects of a person’s life end up contributing to their health beyond the healthcare system, and some of these aspects are detrimental. Let’s look at the interconnectedness of SDOH and a case manager’s role with an actual case report.

A person — we’ll call her Maria — fell down a set of concrete stairs and hit the back of her head. Maria was dazed, doesn’t remember how she even fell and reported she was very unsteady on her feet after she finally was able to stand.


Health and Healthcare.

A missed diagnosis. The first challenge that Maria faced was wondering, “Do I have a serious injury or is this just a bump on my head and I’ll be okay?” Maria is a single mom and works two jobs. Maria doesn’t have health insurance, so a trip to the hospital could be prohibitively expensive and something she’ll likely want to avoid.


Health Literacy.

If Maria’s health literacy is low due to her environment, her family upbringing, her lack of education, language barriers, fear or some past experience, then this can create another, perhaps larger barrier for Maria such as knowing when an injury requires a hospital visit or a call to a community health center. Once Maria finally decides to get care, it may be challenging for her to make informed healthcare decisions.


Maria relies upon the bus for transportation; therefore, travel is an issue and there are no urgent care practices or community health centers nearby. Additionally, when Maria uses transportation, she now experiences extreme nausea and severe migraines for days.


Maria’s family and social circle minimize Maria’s injury, convincing her that she does not need care, telling her that she merely “bumped her head.” These unexplained migraines, constant nausea, forgetfulness, depression and chronic fatigue that have persisted for years are increasing in frequency, and her pain is due to Maria being stressed, working too hard, having “a lot on her plate” as a single mom, having her period and needing to eat better and exercise. These are often excuses that the person’s inner support system rattles off because no one took a moment to ask about the “bump on Maria’s head.”


Maria finally seeks healthcare after years of self-medication, which no longer eases the pain. She is now more confused because the cycle starts all over again when her healthcare provider tells her the same reasons for her symptoms her family did but with additional health conditions. Maria is now pre-diabetic, bordering on high blood pressure, experiences chronic stress and fatigue syndrome, is overweight and is physically out of shape. Maria now has a case manager to assist her with receiving proper care, but the root cause and barriers that exacerbate her chronic conditions are not addressed, causing a round-robin of services with often minimal results.

Could all of this and the future medical costs of Maria’s care have been avoided if barrier #2, health literacy, was minimized so Maria could seek appropriate healthcare, and receive proper treatment for her initial injury? Quite possibly, yes, but we cannot reverse the timeline. What we can do is engage Maria in her own care, recognizing that Maria needs a more supportive environment to foster the patient-provider relationship, while nurturing the Whole-Person Care (WPC) model.3 How? Current processes can make a case manager feel as though they are juggling too many balls while simultaneously dousing fires. We need to consider how to lead the way in creating ownership through active dialogue with patients and minimize the reactive approach. Current processes do not easily support this model since a case manager’s caseload has significantly increased over time.

The solution does not require another assessment or intake form. The answer lies in improving engagement. Engagement that is reinforced through a relationship the case manager creates with their patients without increasing the burden upon a case manager. Successful engagement creates ownership. If a case manager can leverage their knowledge and skills to engage a patient in their own care, outcomes will improve. At first glance, the case manager may believe they are doing this, but the probability is that the case manager is “telling” their patients rather than asking them what their goals are. By shifting the ownership to the patient and helping them refine their goals into smaller, achievable and sustainable steps, the patient realizes their health is improving, thus paving the path for a behavior model of change. The small, digestible Kaizen4 steps will become a new lifestyle. This process is sustainable.

A case manager’s caseload has tripled, possibly quadrupled over the past several years. This untoward growth has increased challenges rather than improved health. Telehealth is not going away, and all models are indicating that it will continue to increase. So, how can a case manager apply the principles described above to encourage change in their patients while shifting their own approach to prevent burnout and improve their patient’s health? Active engagement that incorporates SDOH is a proven solution.

By encouraging patients to track their symptoms and understand the triggers that affect their quality of life, a patient becomes an active participant in their own care, and this is incredibly empowering.

An emerging strategy for improving patient care is to meaningfully include the patient in the care team and healthcare process. If case managers ignore this model, change will not occur. This means engaging the patient and empowering them to contribute to their health and health outcomes. Case managers can expect to see better outcomes and greater retention among their patients who are involved with and are responsible for a portion of their care. Information is power.


1. Loma Linda University Health: Who are Seventh Day Adventists? SC-226-13 Who Are SDA Book d3a.indd (
2. CDC: Social Determinants of Health: Know What Affects Health. Social Determinants of Health | CDC.
3. Rebecca Perez, MSN, RN, CCM, “Integrated Case Management’s Contributions to Whole-Person Care,” CMSA Today, 2021, Issue 1, pp. 14-15.
4. Robert Maurer, PhD One Small Step Can Change your Life: The Kaizen Way. Workman Publishing, New York, 2014.
lynne becker

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Lynne Becker, MSPHis the CEO and founder of, Power of Patients (, which is a patient-led innovative brain injury app that focuses on empowering patients and caregivers to improve their health while providing clinicians with accurate data and accelerating clinical trials. Lynne approaches this from a “What if” perspective. Follow Lynne on Twitter  or connect with her by emailing  to learn how to access this FREE app.


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