How Case Managers Can Improve SDOH Assessments
By Melinda Young
Case managers can use several different tactics to improve their assessments of social determinants of health (SDOH). These may require extra time, but they can yield big rewards in terms of patients’ health and preventing readmissions.1
Here are suggestions on how to improve these assessments:
• Create a trusting environment for patients. “You need to relax them, put them at ease, and give them [openings] to share information they might normally hold back,” says Vivian Campagna, DNP, RN-BC, CCM, chief industry relations officer at the Commission for Case Manager Certification (CCMC) in Mount Laurel, NJ. “I’ve found that the more conversational I made my assessment visit, the better off it was.”
The key is to put patients at ease in the conversation so they will not worry about what they are saying and they can share information comfortably.
“We need much more information to be able to do the best for our clients by understanding what they are, where they are coming from, and what they need access to,” Campagna explains. “It’s very important that we as case managers are very comfortable in asking the questions. As leaders, we need to foster that in our case managers.”
• Allow patients to direct priorities. This requires an open mind about what might be most important to a patient. For instance, a case manager may be interested in finding out why the patient has not been taking medication on schedule. But the patient’s priority could be a family member who is in danger during the conflict in Ukraine, suggests Ellen Mitchell, MA, RN, CCM, director of education and industry relations of CCMC. The patient might not listen to the case manager telling them where to buy their medication at a cheaper price because they are worried about something else entirely.
“You have to meet them where they are and think about unrelated information,” Mitchell explains. “We’ve had situations where social workers have tracked down embassies to find patients’ family members in other countries.”
It is the detective school of case management. “It takes a level of creativity that is like a magician’s level of creativity,” Mitchell says. “You have to be willing to be creative and hear them, understand them, try to help them with their concerns, and then try to move them forward so critical needs get helped as well.”
• Patience, patience, patience. People who are adversely affected by SDOH frequently visit the ED or are admitted to the hospital. Their issues developed over a long period, and the solution also will take longer than case managers might expect.
“It may not be on the first encounter that you get the information you need to truly help the client move on,” Mitchell says. “I always encourage newer staff members and less experienced case managers to develop rapport with the patient, even if there’s a shorter length of stay.”
For example, a case manager can enter the patient’s room with a broad smile, saying, “Good morning.” Each act of friendliness and kindness cracks the ice.
“Sometimes, it will take two or three readmissions before the person says, ‘I live in an apartment with a lot of cockroaches, and it makes my asthma really bad,’” Mitchell explains. “At the first readmission, they may not share that because it sounds awful and degrading, and they don’t want to go there. It’s all about rapport-building.”
• Put the pieces together. “I come from an urban area with a mixed economic basis of patients, and many were undocumented, undomiciled, and uninsured,” Mitchell says. “You may have a woman whose dad is in the hospital, and she can’t take care of him because she’s working three minimum-wage jobs to put food on the table, or she’s working as an undocumented worker for someone — and no work [means] no pay.”
Case managers need this information to put the pieces in place to prevent ED visits. For instance, one case Mitchell recalls involved a man with a respiratory condition who visited the ED because he could not breathe.
“Over time, we found out he shared an apartment with five guys who smoked,” Mitchell says. “We hooked him up with a community health worker to help him get into other housing, and that literally solved the problem.”
• Be creative. Not all solutions fit in the box case managers use most often. Some patient barriers are unique and require equally unique solutions.
Jean Krsnak, MSN, MBA, RN, CCM, recalls the case of a man who revisited the hospital several times a year due to episodes of diabetic crisis.
“When you spoke with him, he seemed to be knowledgeable about diabetes and knew what to do to manage it, so it was a mystery as to why he kept coming back,” says Krsnak, commissioner of CCMC. “One day, I was in there and said, ‘You seem very knowledgeable about what happens from one day to the next when you manage your diabetes.’ He said he lived in a pick-up truck down the street from his sister and brother-in-law, and the brother-in-law wouldn’t allow him in their home.”
The patient stored his insulin inside the refrigerator in his sister’s garage. He could only visit the garage when the brother-in-law was not home. Since the patient was not taking his medication consistently, his vision was fading. He could not read the label to determine the proper dose.
“Once we learned that, we couldn’t do anything about the brother-in-law, but we gave him alternatives for housing that had refrigeration,” Krsnak says. The diabetes coordinator gave him reading glasses and sent him to an eye clinic.
Due to these interventions, the man could better read his medication labels, improve his medication compliance, and stop the progression of his eye disease, Krsnak says.
• Show genuine concern for patients. Case managers need to explore where patients are, what affects their health, and what makes them tick. In other words, they need to care about their patients’ day-to-day lives.
“Sometimes, you can ask simple questions like ‘How do you take your medications in the morning? Where do you buy your food?’” Campagna says. “We need to be comfortable enough in ourselves to ask questions because we truly care, and it matters.”
Once patients recognize a case manager truly cares about them and their health, they are less likely to find questions intrusive and nosy. It takes time and slowing down when meeting with patients.
“Everyone is in a hurry these days because of having six assessments and four more patients,” Campagna says. “We have to slow down ourselves and get patients to know we care.”
Case managers need to learn how to listen to what concerns patients most and to give them full attention. “Find out what’s going on with them, what their issues are, and what their concerns are,” Campagna says. “You have to remind yourself and stop yourself, to listen. Sometimes, I find myself not really listening, but hearing just enough to form a response, and I have to take myself out of that mind frame and focus on what’s being said to me.”
It can be challenging if patients respond to a question with a non sequitur. Their answer may have nothing to do with the original question. “You may say, ‘I see you’re having a hard time with your diet. Where do you get your food?’” Krsnak explains. “And they tell you about a whole different aspect of their life and their kids and stuff.”
A case manager has to listen to their unexpected response and realize the patient is not really hearing the questions because something else is more important to them at that moment. “They’ll start to talk about what’s really important to them, and the first things they mention may not be the same as what the case manager wants to know,” Krsnak says. “You have to keep asking questions, but also be ready to pivot to where the patient’s priorities are, which may not be your priorities.”
• Wait and return when necessary. One way to do this is to listen to the patient’s priorities and then ask to continue the conversation the next morning.
Krsnak recalls a patient and family member of Ukrainian background who could not discuss the patient’s medical issues because they were overwhelmed with concern about their overseas family and the Ukraine-Russia war.
“They were so caught up in the stress of not knowing what was going on with their family in the danger zone, and they couldn’t think about anything else,” Krsnak explains. “I could empathize with that.”
At these times, a case manager could refer a patient to the hospital chaplain or volunteers who could address their concerns. In the case of the Ukrainian patient, the hospital gave the patient and family member enough information about steps they could take to contact their loved ones, and this is all they needed to relax and then address the patient’s health issues.
- 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.
Case managers can use several different tactics to improve their assessments of social determinants of health. These may require extra time, but they can yield big rewards in terms of patients’ health and preventing readmissions.
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