By Toni Cesta, PhD, RN, FAAN


Case management professionals have always known the dynamic relationship between psychosocial issues and clinical outcomes. If our patients’ social and financial issues are not addressed first, then it is likely their clinical conditions and expected outcomes will suffer. Recently, this understanding has expanded beyond the typical social and financial issues case managers and social workers have traditionally used to assess patients. These criteria, called social determinants of health, provide a much broader understanding of the issues patients face in managing their health outcomes.

There is widespread acknowledgement that community-level social determinants — affordable housing, stable employment, reliable transportation, and access to healthy food—are a crucial component of holistic strategies to promote health, well-being, and longevity while also reducing healthcare costs. This month, we explore this concept and what it means for case management professionals, and most specifically social work case managers.

Economic and Social Disparities in Health

The United States spends more on healthcare than any other country at $11,172 per year per person. ($3.6,21%20percent%20of%20total%20NHE.) The average country spends about $3,453 per year. Despite these expenditures, the U.S. ranks 33rd out of 36 Organization for Economic Cooperation and Development nations in infant mortality and life expectancy. ( This means that in 32 other countries, babies are more likely to survive, and people are likely to live longer than in the U.S. How can this be when we spend so much more than other countries?

Additionally, people who are uninsured or underinsured are less likely to receive preventive care and manage their care adequately. Patients often seek care after they are much sicker, adding to a higher cost of care when treating them.

Finally, and perhaps most importantly, healthcare is only one contributor to health and may actually be one of the smaller factors. The quality of the healthcare we receive, the amount spent on it, and continuous medical advances are not the main contributor to individual or population health. Public health leader Lester Breslow said “in the long run, housing may be more important to health than hospitals.” ( The Centers for Disease Control and Prevention reports about 20% of the nation’s health is the result of medical care, 5% the result of biology and genetics, 20% is the result of individual actions, and 50% relates to social determinants of health. (

What Are Social Determinants?

It has long been understood that poverty and other social disparities can negatively affect a patient’s health. Nevertheless, most healthcare settings do not conduct a comprehensive assessment of patients’ social risk determinants. It is increasingly understood that social risks are linked to poor adherence to medical treatments, resulting in worsened health outcomes and higher costs of care. Unfortunately, the notion of social determinants does not always mean something to healthcare providers. Think of social determinants as:

  • Conditions of life, such as how we live, work, move around, and what we eat and drink.
  • The causes of those conditions, such as government policies, social structure, and the actions of powerful organizations.

The medical model of care is based on helping people after they are in trouble. Conversely, managing social determinants is aimed at discovering why people are in danger. It looks at our society’s infrastructure, why it is built as it is, and the resulting consequences of these conditions on our health. One example is corporate decisions related to advertising. Ads for tobacco, alcohol, and health foods have shown disparities in wealthier white neighborhoods vs. poor minority neighborhoods. Racism in our society, combined with discriminatory housing practices, means minorities are at a greater disadvantage as it relates to air pollution, dampness, dust, and pests.

Drivers of Conditions of Life

The drivers of the conditions of life as a well as the drivers themselves are considered social determinants of health.


  • Actions of industries and corporations;
  • Race/ethnic and class-based organization of society;
  • Government policies.

Drivers affect how we:

  • Live: Use economic resources, housing, and neighborhood quality;
  • Eat: Amount of and quality of food available;
  • Work: Job conditions, including physical and psychological;
  • Move: Ease of biking, walking, public and private transport.

Each driver affects our health outcomes. These outcomes include injury, disease, and premature death.

Measuring Social Determinants

There are relatively few tools for actually measuring social determinants of health. Although the categories measured could be summarized across tools, there is wide variation in the categories included in each tool. Little consensus exists for the indicators used to measure social determinant categories.

Nevertheless, the Healthy People 2020 national framework provides a starting point for defining categories of social determinants, including these five categories:

  • Economic stability (employment, food insecurity, housing stability, poverty);
  • Education (early childhood education, higher education, high school graduation, language, and literacy);
  • Health and healthcare (access to healthcare, access to primary care, health literacy);
  • Neighborhood environment (access to healthy foods, crime and violence, environmental conditions, housing quality);
  • Social and community context (civic participation, discrimination, incarceration, social cohesion). (Find out more at:

Twelve categories have been identified as the essential categories of any social determinants of health assessment tool. Some electronic tools are available, including NowPow, which is used at Rush University Medical Center in Chicago. The software directs patients to resources for addressing the identified social determinants at risk. It determines how a patient might benefit from one or more community organizations and provides a care plan with recommendations.

If you do not have access to such software programs, you can consider how to measure selected determinants. Many of these can be open-ended questions as you review them with your patient.

• Demographics

• Economic Stability

- Resource availability

• Employment

- Rate and stability

• Education

- Level of completion

• Food Environment

- Food insecurity

- Quality

- Access

• Health and healthcare

- Insurance status

- Access

- Medication adherence

- Use of primary care

• Housing

- Homelessness

- Physical characteristics of housing

• Neighborhood environment

- Exposure to pollutants

• Physical activity and lifestyle

- Tobacco use

- Drug and/or alcohol use

- Violence

- Physical activity level

• Safety

- Environmental

- Activity

• Social and community context

- Exposure to physical and chemical pollutants at work or home

• Transportation and Infrastructure

- Availability

- Type

- Cost

Social workers should consider how to add these questions to a psychosocial assessment. Every case management department should use a standardized social work assessment tool to assess patients presenting with negative social risk factors. These social determinants can be added to an existing tool or form the foundation of a new tool, and will assist in identifying those complex patients in need of a social work intervention. Such tools should be used in the inpatient and outpatient settings.

Using the Data Collected

Traditional means of identifying complex patients is grounded in the downstream medical model, including chronic conditions, health outcomes, and hospitalization and emergency department use. Providers should consider these downstream factors when identifying complex patients, as they are influenced by social determinants. Care teams must understand their patients’ clinical and nonclinical complexities to make informed, patient-centered care decisions.

Addressing social determinants of health can help organizations participating in value-based care reimbursement. It also can help achieve the Quadruple Aim of better health, lower costs, and improved patient and staff experience. However, current payment systems do not adequately incentivize treating social determinants, ensure sustainability of services, or cultivate community partnerships necessary for approaching health holistically and in an integrated fashion.

Once you have collected these data, you can identify where the patient may need an intervention, change, or other assistance. The level of support the social worker can provide will largely depend on the time he or she spends with the patient. If the social worker is assessing an inpatient, then the best intervention for a high-risk patient would be to refer that patient to a community social worker. If the social worker is community-based, he or she can create a robust, comprehensive plan.

The United States spends less on social services than other developed countries. The largest percentage of the gross national product is spent on healthcare at 17%. Unfortunately, we rank 23rd out of 34 nations in terms of social service spending. Finding the resources to assist patients with social determinants can be difficult and time-consuming. A focus on the most important factors is one way to deal with this. Since homelessness is considered the riskiest variable, it is a good place to start.

Another effective intervention is to send community health workers into the patient’s home to address other risk factors. You may consider starting with the diagnoses representing the greatest opportunity as they relate to social factors, such as asthma, chronic obstructive pulmonary disease, or cardiac disease. Many such programs are associated with community case management programs where lay people are trained and educated to make effective nonclinical home care visits.


One such program is the Protocol for Responding to and Assessing Patient’s Assets, Risks, and Experiences (PRAPARE), which helps health centers and other providers collect the data to understand their patient’s social determinants of health. Such programs are helpful as healthcare providers work to improve outcomes in reimbursement models such as bundled payments, accountable care organizations, and value-based purchasing. Programs like PRAPARE assist providers in identifying and measuring the socioeconomic drivers of poor outcomes and higher cost. Providers can use social determinants of health to define and document the increased complexity of their patients. Other outcomes include transforming care using integrated services and community partnerships to meet the needs of their patients and advocate for changes in their communities.

PRAPARE uses an evidence-based set of core measures informed by research on social determinants of risk domains that predict poor outcomes and high cost. PRAPARE also worked with key stakeholders, such as patients, providers, clinical leadership, nonclinical staff, and payers. It aligns with national initiatives such as Healthy People 2020.

Core Measures in PRAPARE

• Personal Characteristics

- Race;

- Ethnicity;

- Farmworker status;

- Language preference;

- Veteran status.

• Family and Home

- Housing status and stability;

- Neighborhood.

• Money and Resources

- Education;

- Employment;

- Insurance status;

- Income;

- Material security;

- Transportation needs.

• Social and Emotional Health

- Social integration and support;

- Stress.

• Other Measures

- Incarceration history;

- Refugee status;

- Safety;

- Domestic violence.

PRAPARE data analyses have revealed:

  • High-risk populations experience greater social determinants of health risks.
  • The general population faces about five simultaneous social determinant risks.
  • Complex patients can face 10 social determinant risks.
  • Patients with uncontrolled diabetes experience more social determinant risks than patients with controlled diabetes.
  • Types and extent of social determinant risks are related to clinical outcomes.
  • There is a positive correlation between hypertension and the number of social determinant risks a patient faces.
  • Ability to afford medications affects the likelihood of controlling diabetes.
  • Stress affects the likelihood of controlling hypertension.

The most prevalent social determinant of health risks between 2015 and 2017 across health center cohorts in seven states were limited English proficiency, education less than high school, lack of insurance, high levels of stress, and unemployment.

PRAPARE provides users with an implementation and action toolkit. The toolkit includes best practices, lessons learned, and user stories that will the user collect data and respond appropriately to social determinant needs.

Actionable Responses to Social Determinants

Physicians are increasingly aware of the need to identify and address social determinants. In fact, 76% of doctors queried indicated they believe that the healthcare system should cover the costs of connecting patients to services that can address their social needs. Specifically, these physicians indicated they would like to be able to write prescriptions for fitness programs, nutritional food, transportation, and housing assistance. (

The lack of reimbursement for interventions that would improve the health of at-risk individuals is the biggest barrier to implementing effective change. Without addressing the drivers of the conditions that are placing our patients at risk, the unhealthy conditions will persist. Some individuals and organizations are working to draw attention to these drivers. Social change, such as work against the tobacco industry, has resulted in a decline in cigarette smoking.


The question remains as to what social workers can do to help patients. The emphasis in the field of human rights has been placed on political and civil rights, but that is changing. Increasingly, we see a focus on social and economic rights, including the right to health. These rights may require more social work staff that is educated and can access needed services for patients. Additional resources must be provided for ongoing patient support such as community case management.

Finally, care providers must be afforded the resources and time to spend with patients regarding their clinical care management and social needs. Some of these needs can and should be addressed. As with many issues affecting health, social determinants will improve only with comprehensive and sustainable interventions that improve quality of life for our patients. If you can apply at least one significant improvement to each of your patients, you will make a great deal of difference in that person’s life.