Addressing Social Determinants of Health: A Care Coordination Approach for Professional Case Managers.

PURPOSE: Social determinants of health (SDOH) continue to gain attention as the factors that weigh heavily on physical and mental health. In response, professional case managers need to develop a deeper understanding of the entrenched nature of SDOH, particularly the spiraling and compounding effects of economic, environmental, and social factors on the health and well-being of individuals and populations. Professional case managers are essential to helping identify both the barriers experienced by individuals in accessing and receiving the care they need and the resources to eliminate or mitigate those barriers. These responsibilities should be most keenly felt by case managers who are board-certified and therefore held accountable by codes of ethics to ensure justice and fairness. By embedding greater awareness of SDOH into the case management process-from intake and assessment through implementation, evaluation, and across care transitions-case managers can establish rapport with clients (known as "patients" in some care settings) and support improved outcomes through best practices in care coordination, thus contributing to the Triple Aim of improving the health of people and populations and reducing the per capita cost of care. PRIMARY PRACTICE SETTINGS: SDOH impact individuals across the health and human services, including acute care, subacute care, primary care, community-based care, and workers' compensation. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Case management plays a vital role in providing people with episodic care and ensuring adequate follow-up. The latter includes if and how people are able to access the ongoing care they need, including medications (access and affordability), doctors' visits, therapies and other services, healthy nutrition, and more. However, a lack of affordability undermines an individual's ability to receive preventive care and treatment of chronic illnesses and potentially more serious and life-threatening conditions such as cancer. Compounding the impact of affordability can be a lack of transportation that inhibits access to health care professionals, which can affect individuals in both rural and inner-city environments. Although poverty and homelessness play a direct role in SDOH, case managers cannot assume which clients are impacted by these factors and which are not. Higher costs of living, loss of job or reduced income, unexpected expenses, and death of, or divorce from, a partner/spouse can negatively impact a client's ability to access and afford care. With this understanding, case managers can meet individuals where they are to explore how SDOH affects their lives, without judgment, bias, or assumption.

Case Management on the Front Lines of COVID-19: The Importance of the Individualized Care Plan Across Care Settings.

PURPOSE: Since the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the disease known as COVID-19, case management has emerged as a critical intervention in the treatment of cases, particularly for patients with severe symptoms and medical complications. In addition, case managers have been on the front lines of the response across the health care spectrum to reduce risks of contagion, including among health care workers. The purpose of this article is to discuss the case management response, highlighting the importance of individual care plans to provide access to the right care and treatment at the right time to address both the consequences of the disease and patient comorbidities. PRIMARY PRACTICE SETTINGS: The COVID-19 response spans the full continuum of health and human services, including acute care, subacute care, workers' compensation (especially catastrophic case management), home health, primary care, and community-based care. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: From the earliest days of the pandemic, case managers have assumed an important role on the front lines of the medical response to COVID-19, ensuring that procedures are in place for managing a range of patients: those who were symptomatic but able to self-isolate and care for themselves at home; those who had serious symptoms and needed to be hospitalized; and those who were asymptomatic and needed to be educated about the importance of self-isolating. Across the care spectrum, individualized responses to the clinical and psychosocial needs of patients with COVID-19 in acute care, subacute care, home health, and other outpatient settings have been guided by the well-established case management process of screening, assessing, planning, implementing, following up, transitioning, and evaluating. In addition, professional case managers are guided by values such as advocacy, ensuring access to the right care and treatment at the right time; autonomy, respecting the right to self-determination; and justice, promoting fairness and equity in access to resources and treatment. The value of justice also addresses the sobering reality that people from racial and ethnic minority groups are at an increased risk of getting sick and dying from COVID-19. Going forward, case management will continue to play a major role in supporting patients with COVID-19, in both inpatient and outpatient settings, with telephonic follow-up and greater use of telehealth.

Improving Care Transitions to Drive Patient Outcomes: The Triple Aim Meets the Four Pillars.

PURPOSE: The purpose of this article is to examine how case managers can support positive outcomes during care transitions by focusing on the goals of the Triple Aim () and Coleman's Four Pillars (). Case managers can play a pivotal role to ensure high-quality transitions by assessing patients and identifying those who are at high risk; coordinating care and services among providers and settings; reconciling medications; and facilitating education of patients and their support systems to improve self-management. These activities are congruent with an underlying value of case management as defined by the Code of Professional Conduct for Case Managers: "improving client [i.e., patient] health, wellness and autonomy through advocacy, communication, education, identification of service resources, and service facilitation" (). CASE MANAGEMENT PRIMARY PRACTICE SETTINGS: Case managers across health or human services must assess for, identify, and understand the vulnerability of patients during care transitions and must adopt best practices to support successful care transitions. This includes case managers in acute care, primary care, rehabilitation, home health, community-based, and other settings. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Two frameworks that support care transitions are the Triple Aim of improving the individual's experience of care, advancing the health of populations, and reducing the costs of care (), and Coleman's "Four Pillars" of care transition activities of medication management, patient-centered health records, follow-up visits with providers and specialists, and patient knowledge about red flags that indicate worsening conditions or drug reactions (). From a case management perspective, these approaches and their goals are interrelated. As an advocate for the individual and at the hub of the care team, the professional case manager engages in important activities such as facilitating communication across multiple providers and care settings, arranging "warm handoffs," undertaking medication reconciliation, and engaging in follow-up, particularly with high-risk patients. To support successful transitions of care, case managers must adopt best practices and advocate within their organizations for systematic approaches to care transitions to improve outcomes.

Case Managers on the Front Lines of Opioid Epidemic Response: Advocacy, Education, and Empowerment for Users of Medical and Nonmedical Opioids.

PURPOSE: The purpose of this article is to examine how case managers, taking a holistic, patient-centered approach that is grounded in advocacy, have a crucial role to play in the opioid crisis response. This includes providing education, support, and resources to prevent misuse of and addiction to opioids prescribed for pain management and intervening with more resources to help combat the nonmedical use of prescription opioids and heroin. PRIMARY PRACTICE SETTINGS: In addition to case managers in acute care, workers' compensation, and palliative care, who have frequent contact with patients who are prescribed opioid medications for pain management, all case managers may interact with patients and support systems/families who are directly or indirectly impacted by opioid use, misuse, and addiction. IMPLEMENTATIONS FOR CASE MANAGEMENT PRACTICE: The broad scope of the opioid epidemic necessitates individualized interventions to address the multiple needs of individuals. The case manager, particularly one who is board-certified, has the expertise and knowledge to assess individual needs, identify treatment and other resources, and provide education and support to the patient and family/support system. In addition, given the complexity and life-or-death consequences associated with the opioid crisis, a timely and comprehensive approach is essential, bringing together multiple disciplines in health care, public health, addiction, pain management, social work, mental health counseling, pharmacology, and case management.