The social drivers of health (SDoH) can affect a wide range of health outcomes and quality of life outcomes. There are five common domains; economic stability, education, health and healthcare, neighborhood and built environment, and social community context. We seek health equity for all. According to a Cleveland Clinic Health Essentials article, “Living with health inequity has a wide range of consequences. People who are marginalized by society (or who come from disadvantaged communities) tend to have more chronic diseases and poorer health outcomes.” A recent study in the KFF report found that American Indian and Alaska Native (AIAN) (67.9 years) and Black (72.8 years) people had a shorter life expectancy compared to white people (77.5 years) as of 2022; and AIAN, Hispanic and Black people experienced larger declines in life expectancy than white people. This data is enlightening, but how can we as case managers provide support and how do we provide education ourselves on factors that contribute?
Exploring the impact of health equity and the role of the professional case manager using health literacy may be an effective approach. The social drivers of health, also known as the social determinants of health, consider factors such as transportation, health literacy and their living environment. There is an opportunity to expand the understanding of SDoH, as a recent report indicates 46% of Americans are not familiar with this concept. The professional case manager can use health literary as an intervention to address their knowledge gap. The CDC defines health literacy as the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions. The focus is not just to understand it but use it by making well-informed decisions.
Health literacy is connected to health equity (CDC, 2024). As healthcare practice continues to evolve with a focus on disparities and inequalities, evaluation of access will be at the forefront of service delivery. Health equity ensures there are fair and equitable chances for individuals to be as healthy as possible. Prioritizing health equity can translate in eliminating problems such as poverty and discrimination, and their consequences. “Those in need of healthcare services need to apply a wide range of health literacy skills to obtain healthcare coverage, access services, communicate with healthcare providers and understand their options and act on them.” Case managers have an important role in this process such as communicator, collaborator and advocate providing comprehensive care in complex medical situations. Health literacy skills training for case managers is critical to improving patient outcomes and ethical conduct and reducing health disparities: enabling healthcare providers to provide equal care to all patients regardless of health, race, ethnicity, gender or other factors. Sometimes clients don’t know what they don’t know. Case managers are ideal in supporting clients in improving their health literacy and awareness. First, we need to understand ourselves. Let’s explore some areas of concern: emergency room access, maternal health, environment, cultural representation, community and transportation.
To understand the gravity of the connection of health disparities and inequality to access, the data reflects the current state in terms of emergency room access and care. Our discussion will include these areas of concern: longer wait time, decreased admission rates, affordability, underinsured and noninsured and mental health. A recent study indicated that in emergency rooms, African American experience longer wait times at a rate four times longer than white people. In addition, African Americans were less likely to be admitted to the hospital. Affordability is another barrier to healthcare in which, according a recent KFF report, nonelderly AIAN (19%) and Hispanic (18%) people were more than twice as likely as their white counterparts (7%) to be uninsured as of 2022. The report shared that mental health treatment in adults with any mental illness, Hispanic (40%), Black (38%) and Asian (36%) adults were less likely than white adults (56%) to receive mental health services. How do we support this population to ensure they receive the needed services? As case managers, we have a responsibility to explore, educate and support. Health literacy can be impactful.
Another concern is the growing initiative focusing on Black maternal health and infant mortality that has been established. The data reflects that Black (10.9 per 1,000) and AIAN (9.1 per 1,000) infants were at least two times as likely to die as white infants (4.5 per 1,000). Black and AIAN women also had the highest rates of pregnancy-related mortality. Health literacy can address the preventative and education needs related to healthy pregnancy and infant health in vulnerable communities.
We should understand the impact of one’s environment and how it affects health. Food insecurity, food deserts and the quality of drinking water can have a major impact. In relation to food insecurity, AIAN (24%) and Black (21%) children were more than three times as likely to have food insecurity as white children (6%), and Hispanic children (15%) were over twice as likely to have food insecurity than white children (6%). Exploring food deserts and access to food resources is an intervention of the professional case manager. Education about how to access food resources in the community is helpful as well. According to the CDC, the quality of tap water depends on two factors: water source and treatment. Quality water is very impactful as 9 out of 10 people get their water from a public water system. Drinking water contamination is widespread, even in the United States. Exposure risk profiles vary by contaminant (Levin, R., Villanueva, C.M., Beene, D, 2023), and increasing health literacy can be an effective intervention by training case managers on these risks.
Access to healthcare requires that patient experience and treatment by healthcare professionals is considered and is received more favorably and responsively from providers that represent their culture. A study by Dr. Kenneth Poole, indicates that people of all races prefer to be seen by a provider of the same race. In terms of Black men accessing care, there was an increase in accepting preventative services when offered by a Black physician. The CDC shares that cultural humility is best demonstrated in organizations that have the awareness and engagement in the community. This includes the knowledge of the needs of the community being served and developing services that meet those needs.
Providing healthcare can be a challenge in rural areas. Home-based services eliminate the need for transportation and provide the services in the patient’s environment. Typically, case managers specialize in home-based care providing in-home supports that embraces the needs of the patient. Clinical case management interventions may include application of the SDoH framework. Acknowledging the value of health literacy and culture competency strengthens the role of the case manager.
As previously mentioned, the social drivers of health are those non-medical factors such as employment, education, housing, transportation and safe environment that impact health outcomes. Professional case managers can utilize health literacy to address the knowledge gaps around SDoH to improve health outcomes. Use of a screening process upon admission and intake may help link the patient to additional services. In 2024, hospitals are required by the Centers for Medicare & Medicaid Services (CMS) to screen for the SDoH, as a result impacting the practice of case managers. Establishing effective screening tools will enhance patient experience, quality of care and targeted health literacy. Therefore, developing training and awareness for case managers would be effective in ensuring that the SDoH are addressed in the healthcare setting.
Awareness of health equity may be the start of transforming the current standards of practice. This includes working toward a state of health equity that ensures clients have access to fair and equal healthcare. Being a more inclusive and culturally competent case management workforce affords an opportunity to provide client-centric care. As professional case managers, having clinical competence is an expectation related to ethical practice. Professional organizations have standards that guide the principles of providing the best care based on the client need. This includes ensuring that healthcare access is equitable and fair. Recent changes by CMS require healthcare organizations to develop key strategies and plans to improve access, coordination and affordability of care for patients. There are opportunities to use health literacy as a systemic response to the barriers to care. In addition, preparing the case management workforce for the changes by providing clinical competency in health equity along with monitoring and oversight should improve the quality of healthcare services.
Establishing case management training that incorporates the principles of health equity and the application of the social drivers of health to screen for barriers or challenges to accessing care is necessary. An evolving problem that continues to impact the overall wellbeing of individuals and the population centers around accessibility. Another aspect of that is the affordability of care to include medical treatment, evaluation and medications. Development of a standardized screening and evaluation process can assist the professional practice of the case manager. This process would enhance service delivery in the most vulnerable rural and urban areas of the country. Expansion of telehealth services can enable increased prevention and education services as well. Monitoring of health outcomes including medication adherence along with health behavior can impact chronic illness and disease.
Healthcare organizations can use strategic planning to set specified goals related to meeting the standards of health equity and organizational health literacy. Aspirational goals focus on challenging the current process to create a shift or growth in an organization. There are some benefits to establishing health equity as an aspirational goal and focus on targeted outcomes. The standard of health equity includes decreased wait times and addressing delayed treatment; focusing on accessible and affordable care related to policy implementation and procedures; and providing additional case management support for vulnerable populations to assist with health prevention and treatment. This may include having a designated role within the organization to lead the changes in service delivery. Aspects of the role may focus on health literacy and training of the healthcare workforce. The role of health equity aligns with the standards of practice for case management. Identification of the systemic barriers in providing quality care can help streamline the change process. Providing access to healthcare that is affordable, focusing on quality, will enhance the population health outcomes. Case managers have a key role in driving this change by facilitating and linking the resources to the patients. The future of healthcare centers on addressing needs from a health equity framework.
REFERENCES
Allen-Meares, P., Lowry, B., Estrella, M. L., & Mansuri, S. (2020). Health Literacy Barriers in the Health Care System: Barriers and Opportunities for the Profession. Health & social work, 45(1), 62-64. https://doi.org/10.1093/hsw/hlz034.
Center for Disease Control (2024) https://www.cdc.gov/minority-health/index.html.
Center for Disease Control (2024) https://www.cdc.gov/health-equity/core/health-equity-fact-sheet.html.
Center for Disease Control (2024) What is Health Equity? | Health Equity | CDC. https://www.cdc.gov/health-equity/what-is/index.html.
Center for Disease Control (2024). Embracing Cultural Humility and Community Engagement | Global Health Equity | CDC. https://www.cdc.gov/global-health-equity/php/publications/cultural-humility.html.
Cleveland Clinic Health Essentials (2024). Why Health Equity Matters (clevelandclinic.org). https://health.clevelandclinic.org/health-equity.
Elevance Health (2024) What’s Driving Our Health Study | Elevance Health. https://www.elevancehealth.com/research/social-drivers-of-health/whats-driving-our-health.
KFF (2024). https://www.kff.org/key-data-on-health-and-health-care-by-race-and-ethnicity/?entry=executive-summary-introduction.
The Joint Commission (2024). https://www.jointcommission.org/our-priorities/health-care-equity/accreditation-resource-center/make-health-care-equity-a-leader-driven-priority/.
Levin, R., Villanueva, C.M., Beene, D. et al. US drinking water quality: exposure risk profiles for seven legacy and emerging contaminants. J Expo Sci Environ Epidemiol 34, 3-22 (2024). https://doi.org/10.1038/s41370-023-00597-z.
Macias-Konstantopoulos, W. L., Collins, K. A., Diaz, R., Duber, H. C., Edwards, C. D., Hsu, A. P., Ranney, M. L., Riviello, R. J., Wettstein, Z. S., & Sachs, C. J. (2023). Race, Healthcare, and Health Disparities: A Critical Review and Recommendations for Advancing Health Equity. The western journal of emergency medicine, 24(5), 906-918. https://doi.org/10.5811/westjem.58408.
Neshan, M., Padmanaban, V., Tsilimigras, D. I., Obeng-Gyasi, S., Fareed, N., & Pawlik, T. M. (2024). Screening tools to address social determinants of health in the United States: A systematic review. Journal of clinical and translational science, 8(1), e60. https://doi.org/10.1017/cts.2024.506.
Poole, KD (2019) Patient-Experience Data and Bias—What Ratings Don’t Tell Us www.nejm.org/doi/full/10.1056/NEJMp1813418.
US Veteran Affairs Office of Health Equity (2024) Office of Health Equity Home (va.gov).
, MSW, LICSW, has worked at Veterans Affairs for 16 years, with four of those years being in Veterans Integrated Service Network (VISN) 5. She has been working with the Northeast Consortium (VANEC) as a care coordination and integrated case management (CC & ICM) lead since 2021. Anita previously served as the VISN 5 Caregiver Support Program coordinator and worked in various roles within the Caregiver Support Program from 2011 – 2021. Anita has 15+ years’ experience in integrated case management providing care coordination to vulnerable seniors in the Washington DC community. She also has experience in project development, project coordination and management consulting. Anita received her BA in International Studies at Mount Vernon/George Washington University and Master’s of Social Work at Howard University both located in Washington, D.C.
, RN, MSN, CCM, CPHQ, CPHM, regional nurse consultant for Care Coordination and Integrated Case Management (CC & ICM) and Referral Coordination Initiative (RCI) in Veterans Integrated Service Network (VISN) 15. She has been in the VA for 38 years and has had many leadership experiences. She is recognized as a national subject matter expert for case management and staff development with a focus on self-care. Words can’t describe the unbounding satisfaction she acquires when she is serving our nation’s heroes. She is passionate about quality of care, case management and caring for others. She believes in servant leadership, just serving.
, DHA, MPH, MSW, LCSW, a field consultant for the Southeastern Network Consortium (SSNC) located at the VISN 8 Network Office in Tampa, Florida. She has been in VA for 21 years with extensive experience in healthcare management and service delivery related to program implementation to enhance veteran experience. She is an avid Change Management practitioner as a Lean Six Sigma Black Belt Trained, Transformation Coach, and VHA Certified Mentor. Since 2016, Dr. Rayner has worked with the VA National Social Work and Care Management Office in the implementation of the CC & ICM framework in the VHA.
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