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Health Equity and SDOH: The Impact of CCM

Jon-Michial Carter
Written by Jon-Michial Carter

Social Determinants of Health (SDOH) have a significant impact on patients’ health outcomes. To achieve health equity for people from all demographics, healthcare organizations must recognize and address SDOH needs. This is true for all practices, but especially for those that serve high-need populations, such as those who are older, disabled, low-income, rural, or battling multiple conditions.

Preventative care programs, like Chronic Care Management, are specially equipped to address SDOH concerns because they offer consistent, ongoing care. Since care coordinators check in with patients regularly, they can focus on a patient’s long-term needs, rather than immediate health problems. Through monthly check-ins, care goals, and help with community resources, CCM can empower practices to address Social Determinants of Health and work toward health equity for all patients. 

Social Determinants of Health

The U.S. Department of Health describes the five dimensions of Social Determinants of Health as:

1) Economic stability
2) Access to quality education
3) Access to quality healthcare
4) Neighborhood and built environment
5) Social and community context

The domains are interconnected: to provide quality healthcare, providers and healthcare staff must account for patients’ economic circumstances, health education, built environment, and social context. 

Economic stability affects a person's ability to afford medication, healthy food, and safe, clean housing. People who are financially comfortable are more likely to have quality education, which leads to greater health literacy. Patients who understand their conditions and how to manage them have greater chances of adhering to medication regimens and care plans created by their provider.

Patients also have greater control over their health when they live in safe communities with opportunities to exercise outside, buy healthy groceries, and engage with community resources like art classes, book clubs, or support groups. Additionally, healthy neighborhoods and communities will offer reliable public transportation or car services so patients can reach their medical appointments and community activities, giving patients strong social ties. 

The examples above are just a few of the Social Determinants of Health factors practices need to screen for and address when thinking about health equity. 

Addressing SDOH Through Preventative Care

While most healthcare practices want to screen their patients for Social Determinants of Health, they don’t always have the resources to do so, especially when they’re understaffed. 

Care coordinators, like those used in Chronic Care Management programs, are equipped with resources to screen patients for SDOH needs and connect them with support services. 

The resources care coordinators can direct patients to include: 

  • Food pantries or delivery services
  • Housing agencies
  • Clothing closets
  • Support groups
  • Exercise groups for seniors, like Silver Sneakers
  • Transportation agencies

And many others. 

Transportation needs come up especially frequently as part of CCM. CCM serves Medicare recipients, a population who may no longer drive. Therefore, finding transportation to medical appointments and social activities can be difficult. Care coordinators can help arrange transportation so patients receive the preventative care they need and remain actively engaged in their communities.

But the social resources CCM can provide aren’t limited to transportation. Care coordinators can assist patients with finding nutritious food, safe places to live, emotional support, and other resources they need to take care of all aspects of their health. Because of this, CCM has an essential role to play in health equity initiatives. 

The Role of CCM in Health Equity

Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and other practices in rural or low-income areas play a vital role in advancing health equity and addressing the needs of underserved patients. To support these organizations, the Centers for Medicare & Medicaid Services (CMS) reimburses CCM at higher rates for FQHCs and RHCs.

RHCs, FQHCs, and practices with similar demographics serve patients that frequently experience economic instability and other SDOH challenges. These patients may live in food deserts, with limited access to nutritious food. They may also work multiple jobs, not have a car, or live long distances from healthcare, all factors that make attending regular appointments difficult.

Because CCM offers access to SDOH resources and includes remote preventative care, it’s uniquely equipped to address the specific needs of rural and low-income patients, including RHC and FQHC patients. 

Addressing Rural Healthcare Challenges

Rural residents are more likely than urban residents to suffer from multiple chronic conditions and to die from conditions such as heart disease, cancer, and stroke. This discrepancy has several root causes, including:

  • A shortage of healthcare professionals in rural areas
  • Long distances from healthcare facilities
  • Higher smoking rates
  • Limited access to nutritious food

Less than 10% of the nation's providers practice in rural areas, although 15% of the American population resides there. This disparity leads to overworked providers who may not have the time and resources to meet patients’ preventative care needs. 

Patients may also hesitate to seek preventative care if they live too far away from providers.  In 2021, the U.S. Government Accountability Office reported that rural residents traveled an average of 20 miles farther for inpatient care and 40 miles farther for specialty care than urban residents. 

While CCM cannot remove all of these obstacles, it can help practices address them. CCM care coordinators provide care remotely, so they can reach out to patients in their own homes, no matter where those patients live or where the care coordinators are located. Rural patients can receive preventative care via phone, text, email or direct mail in between provider visits, without having to travel. The care coordinator can then report back to their provider on any healthcare needs that the provider needs to address. 

Chronic Care Management can also assist with helping patients form healthier lifestyle habits. Care coordinators can help with specific strategies for smoking cessation or advice for preparing provider-approved, healthy meals. They can also direct the patients to resources in their local area, like support groups, food pantries, or food delivery services. 

Addressing FQHC Challenges

Medicare patients at Federally Qualified Health Centers face some of the same challenges as rural Medicare patients and some very different ones. Unlike RHC patients, FQHC patients may live in large cities with multiple healthcare systems and hundreds of providers. But they could still have trouble accessing care because they lack transportation, need to work strict hours, or find preventative care too expensive. 

FQHC patients also face many of the same obstacles to living healthy lifestyles that RHC patients do. Healthy food might be overly expensive or difficult to find, and their neighborhoods might not offer safe places to exercise. People with lower incomes are also more likely to smoke, even in urban areas. 

Care coordinators can support these patients by offering preventative care at flexible times and at the convenience of home. ChartSpan even offers pre-scheduled call times so patients can choose one that fits their schedule. During these calls, care coordinators can direct patients to food delivery services, farmers’ markets, senior exercise groups, and smoking cessation services in their cities. They can also follow up on patients’ goals and provide support and accountability every month. 

Effects of Chronic Care Management on Health Equity

Chronic Care Management plays a pivotal role in addressing health equity and Social Determinants of Health. By providing consistent care and directions to resources, CCM helps mitigate the challenges of economic instability faced by many patients, especially patients at RHCs and FQHCs. 

If you would like to learn more about how CCM can provide resources and improve health outcomes for patients, you can read our whitepaper on CCM and patient empowerment.

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