The quadruple aim healthcare model continues to evolve as healthcare providers realize the importance of social determinants of health.

  • The quadruple aim includes improving provider satisfaction.
  • Healthcare professionals need to develop a trusting relationship with patients, which is part of the quadruple aim’s goal of enhancing patient experience.
  • One tactic is to give patients confidence in their ability to manage their own healthcare.

The case management and healthcare world grew and evolved in the nearly two years since the start of the COVID-19 pandemic. The quadruple aim model for quality healthcare has evolved as well.

The quadruple aim includes:

  • Improving population health;
  • Lowering cost of care;
  • Enhancing the patient experience;
  • Improving provider satisfaction.1

“It’s a whole different world now with the pandemic, when compared to a couple of years ago,” says Susie Ratterree, BSN, RN, CCM, president of the Case Management Society of America Foundation. “A lot of the best practices we used to meet the quadruple aim are having to be rethought, especially in terms of delivery of care and customer service. One of the biggest things is social determinants of health.”

The quadruple aims of improving population health and provider satisfaction also must be addressed. It has become an issue at a time when healthcare professionals find that just doing their best to prevent infection and save lives can become part of pandemic politics.

“We have to go back to square one,” Ratterree says. “Messaging over the vaccine and masking did not work well. Unfortunately, this pandemic was allowed to become politicized.”

People are making healthcare decisions based on their political views and philosophy instead of focusing on their own health and the health of their families and neighbors.

“We need to develop a trusting relationship, and the place to begin is with patients’ own providers,” Ratterree adds. “Providers should make all kinds of attempts to educate them and talk about the importance of the vaccine and address their fears.”

From a case manager’s perspective, developing trust is paramount. It is particularly challenging during the pandemic.

“I’ve found that once I’ve introduced myself to a person, I ask the questions of ‘How are you feeling?’ and “How did you get here?’” Ratterree says. “Then, I sit back and truly listen to what they’re saying, and I make sure I understand and am nonjudgmental.”

Patients who feel judged will clamp down, and it will be hard to build trust. One example of broaching behavior change subjects without judgment involves infection prevention actions. A case manager could start talking about how washing hands often will help prevent the spreading of germs.

“If you’re listening, you may find out the person has a small child or someone who is vulnerable. You bring that situation into your teaching and say, ‘Hey, grandma is going through chemotherapy, and it’s really important she doesn’t get exposed to germs,’” Ratterree explains. “‘When you’re visiting with grandma, you can wash your hands really well because it helps her.’”

Case managers can use stories from their personal experience, if they are comfortable with sharing. These anecdotes engage patients and let them know they are not the only ones experiencing health challenges.

The goal is to meet patients where they are and try to help with education and confidence. “Give them confidence in their ability to manage their healthcare,” Ratterree says. “Once you gain their trust and give them enough education that they start to see the benefit, reinforce that [behavior change], saying, ‘Hey, you’re doing really good.’”

Case managers can tell patients it is OK if they forget to maintain their healthy habits once in a while as long as they get back up and improve the next day.

The quadruple aim also should be expanded to include social determinants of health. “Social determinants of health will help us understand our patients better and help us come up with a care plan that will help them reach the outcomes and be the best they can be,” Ratterree says.

The types of social determinants of health affecting patients varies by person. “Look at the community, the educational level,” Ratterree says. “There are a lot of different components.”

For instance, some patients have not graduated from high school, and might possess low health literacy. They could be distrustful of highly educated people giving them advice.

“If we don’t understand where they’re coming from, and if they have a history of not trusting the healthcare system, then it’s up to the case manager to try to change that and develop a trusting relationship with them,” she says. “If they don’t trust the medical community or their case manager, the education we’re trying to give them about their health condition will go in one ear and right out the other.”

The case management goal is to help patients change their lifestyle behaviors and mitigate risk. One of those risks involves vaccination against COVID-19, which creates challenges.

“It’s difficult with trying to get the messaging out about the benefits of the vaccine and hazards of the pandemic,” Ratterree says. “I’ve heard some older folks say, ‘I’m not going to get the vaccine,’ and it could be they have never had a vaccine at their age. Or, they may come from a community that is very distrustful of an authoritarian institution like the medical community.”

Case managers will not influence patients if they do not understand these cultural aspects.

“You have to figure out how to help them understand this vaccine might have come out quickly, but the technology or research has been going on for years and years on this type of vaccine,” Ratterree says. “Those are things that we as a medical community are missing the message on sometimes, especially with this pandemic.”


  1. Strategies for Quality Care. Quadruple aim: A framework for achieving value-based care.