Case Management Leaders Advocate for Improved SDOH Assessments
By Melinda Young
EXECUTIVE SUMMARY
Improving social determinants of health assessments will help the healthcare industry evolve and improve medical care and efficiency.
- Case management leaders should collect data to show hospital leaders how their work with social determinants can help a health system meet its goals.
- Collecting data takes time and requires case managers to dig deep into patient’s social circumstances.
- One tactic is to become comfortable observing patients and asking them about their lives and healthcare barriers.
As the healthcare industry continues to evolve and change, one best practice case managers can follow is to assess social determinants of health (SDOH) as thoroughly as possible.
“There is a huge opportunity for case management leadership to advocate for further assessment of social determinants of health for the entire team,” says Jean Krsnak, MSN, MBA, RN, CCM, commissioner of the Commission for Case Manager Certification (CCMC) in Mount Laurel, NJ. Krsnak recently retired as acute care case manager at UC Irvine Medical Center.
While case management is vital to providing people with episodic care and adequate follow-up, a chief obstacle is lack of affordability. Patients may be unable to receive preventive care and treatment of chronic illnesses.1 This is why it is more important than ever for case managers to focus on SDOH, which often include healthcare obstacles related to financial concerns.
Case management leaders need to advocate for their staff to learn all they can about patients’ SDOH.
“One of the things the C-suite needs to value is the time it takes to have these conversations with patients,” Krsnak says. “You don’t get too far if you use a questionnaire and ask questions 1, 2, 3, 4, 5; you need conversations with patients, and that takes time to develop.”
It is easier on case management teams if their leader is willing to make their case to the C-suite with data.
“There’s a lot of evidence to support a positive return when we address social determinants of health. I don’t know how many hospital administrators realize that,” Krsnak says. “Awareness of social determinants is probably best the closer you are to the bedside. The staff taking care of patients would have the highest awareness of it. As you go up the food chain, we can’t assume the awareness is there or that they are aware of the connection between social determinants and outcomes. We have to make them aware of it.”
Hospital leadership looks at financial data, quality scores, and patient satisfaction surveys. Case managers need to provide them with these kinds of data from internal numbers and studies.
Case management leaders can make the case for their services. Through diligent data collection, they can show leaders that focusing on SDOH is crucial to a health system’s mission, says Ellen Mitchell, MA, RN, CCM, director of education and industry relations for CCMC.
“In a couple of organizations where I worked, we knew the names and information for every person with X number of admissions over a six-month period,” Mitchell explains. “We drilled down to get the data.”
Over time, they saw results. Some patients stayed out of the hospital and were living in better health. This proved the tactic helped improve outcomes, Mitchell adds.
Case managers also need to collect data on what conversations took place and which referrals and interventions were used to address SDOH. They also can track patients’ admissions and ED visits.
“You have to collect data to prove your point that an expanded [case management] program would make it better,” Mitchell says.
But collecting data requires digging into patients’ social determinants and issues. Sometimes, patients omit important information to defend their own pride.
“People want to maintain their dignity as well as privacy, and they don’t want someone uncovering all these things they may find embarrassing and shameful,” Krsnak explains. “Your opportunity to have an ongoing relationship with patients is very limited in a hospital setting, where people come and go.”
Since it is challenging to develop continuity with patients admitted to the hospital, it is essential for case managers to forge strong trust-based relationships from the start. This takes time.
“Case managers have to become more comfortable and ask people in a confident tone [about their lives],” says Vivian Campagna, DNP, RN-BC, CCM, chief industry relations officer at CCMC.
Build Interdisciplinary Relationships
Case managers know how to observe and learn more about patient’s lives and their barriers to care, particularly their SDOH. But they may not always discover important details because patients can be reticent to share their struggles. (See story in this issue on improving SDOH assessments.)
One tactic is to build relationships with other members of the healthcare team. “It’s been my experience that patients have the ability to decide which staff members have time to listen to them,” Krsnak says. “They’re more open to talking to people they think have time to listen to them.”
These good listeners could be nursing assistants, housekeeping staff, dietary staff, and the person wheeling them to the elevator, as well as nurses and physicians.
“On a busy floor, patients will talk with nursing assistants at length,” Krsnak says. “They think nursing assistants have time to listen.”
If case managers establish relationships with nursing assistants, unit secretaries, and anyone with patient contact, they can understand the patient’s situation better thanks to pieces of information these staff members offer. Case management leaders need to foster the interdisciplinary team concept.
“That includes housekeepers, dietary folks, people who deliver the trays,” Campagna says. “Everyone has a different rapport with the patient, and patients will respond to people in different ways.”
For instance, the housekeeper may enter a patient’s room and find them crying in bed, alone. By asking what is wrong, the housekeeper may learn something important the case manager was unable to obtain from the initial meeting and assessment.
“We need to make everyone feel they are part of the team, regardless of their profession or job function,” Campagna says. “Everyone can have input into the patient, and everyone can give us information. No information is silly or unimportant.”
Nursing and housekeeping staff spend a lot of time in patients’ rooms, helping with washing and cleaning. “A lot of chatting happens,” Mitchell notes. “When the housekeeper goes in and is sweeping, they’re chatting.”
The person cleaning the room might mention using a new mop, and the patient says, “I can’t clean my house anymore,” Mitchell says. “If the housekeeper is part of the team, we may get that nugget of information that tells us the patient needs help with housekeeping,” she adds. “In the course of an assessment, who is going to ask, ‘Can you mop your floor?’ No one is going to ask that, so this is how you get these insights.”
Curiosity is a great tool for case managers. “Always be curious about what’s happening, and always learn something,” Campagna says. “You can learn something from anyone.”
Silver Lining
While the past few years of the COVID-19 pandemic have made it more challenging for case managers to assess patients’ SDOH, there has been one silver lining.
“The silver lining was you had to be living under a rock to not hear every day that a disproportionate number of people of color were [contracting] COVID-19 and dying, or having terrible access issues in getting the vaccine,” Mitchell says. “‘Social determinants of health are real and are killing your neighbors’ is what people heard. We’ve known about social determinants of health for years and years, but it took something of the pandemic’s magnitude for us to say, ‘This is really bad.’” It is possible the nation’s healthcare enterprise will improve, she adds.
The pandemic also raised awareness of the community and how an illness could affect the entire healthcare system. It forced hospitals to improve safety through better discharge plans, and it reinforced the idea of SDOH to people who otherwise did not know the term or believe they played a role in improving their community’s health, Krsnak says.
“The silver lining is it brought home the fact that there are major inequities in different communities and major issues in terms of people having access to care or treatment or vaccines,” Campagna says. “COVID hit everyone, and no one was unscathed.”
REFERENCE
- Campagna V, Mitchell E, Krsnak J. Addressing social determinants of health: A care coordination approach for professional case managers. Prof Case Manag 2022;27:263-270.
Improving social determinants of health assessments will help the healthcare industry evolve and improve medical care and efficiency. Case management leaders should collect data to show hospital leaders how their work with social determinants can help a health system meet its goals.
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