Social Determinants of Health: Chronic Care Management Program Role & Responsibilities

Chronic care management is a service that helps to coordinate the delivery of services for patients with complex chronic health conditions. In this article, we explore the social determinants of health (SDOH) and chronic care management programs' role in addressing SDOH. By understanding the conceptual framework behind these two important topics, you will be better equipped to understand how they intersect and affect your clients' lives.


What is Chronic Care Management?

Chronic care management is a process designed to help people with chronic conditions manage their health and well-being. It's a program that helps people manage their chronic conditions, as well as the social determinants of health (SDOHs) that contribute to these conditions. This can include:

  • Accessing information about what it means to be healthy or sick;

  • Having access to reliable sources of care;

  • Balancing personal priorities with those of others who depend on them for support; and/or

  • Changing lifestyle behaviors that contribute to SDOHs such as smoking, drinking too much alcohol, or eating unhealthy foods without taking steps toward healthier choices.

The social determinants of health (SDOH) are factors such as income level or education that affect people's ability to get the care they need when they need it most. In other words: If you don't have enough money for food but you're hungry because your job doesn't pay enough money; if your kids can't afford new clothes every year but they're still going through old ones—it's likely one or both will suffer from poor nutrition or lack of basic hygiene during childhood development stages which can lead into adulthood issues later on down the road! These types of situations require special attention from case managers who understand how these issues may affect an individual's quality of life over time—and therefore must be addressed immediately before problems become worse which could eventually lead back into homelessness again.


Program components that encompass two or more SDOHs

Social determinants of health (SDOHs) are the social, economic, and cultural conditions that influence health. They include:

  • Housing - housing quality and quantity;

  • Employment – employment status, income, or wages;

  • Transportation – access to transportation;

  • Education/training – educational attainment levels, education attainment disparities between different racial/ethnic groups within society, and gender inequality;

  • Income adequacy – income adequacy among low-income families in relation to other family types at home or workplace settings (e.g., single-parent households);

  • Food insecurity - food consumption patterns among participants who report hunger on a regular basis during the week prior to the interview.


Consumers living with complex chronic conditions are at the greatest risk for negative outcomes from SDOH.


The social determinants of health are the conditions that shape a person's ability to live a healthy life and cope with the disease. They include unequal access to education, nutrition, housing, and health care; discrimination based on race or ethnicity; poverty; low voter turnout; limited participation in civic life (such as voting); lack of political representation for certain groups such as women and people with disabilities.


These factors contribute to chronic conditions—long-term medical problems that can lead to disability or death. According to SDOH, it is estimated that Americans have more than 20 million people living with some form of SDOH at any given time (1). Chronic conditions such as cancer are often linked together because they share common risk factors like a diet high in processed foods that may be high in sodium content (2).


SDOHs addressed in other program components

Case managers are charged with integrating the CCM program into their organization’s existing care management system. They must understand that chronic conditions aren't just about managing symptoms or preventing future occurrences; they require a long-term perspective and planning. This means that case managers should be able to identify how an individual's health status will affect his or her ability to work, participate in society, and enjoy life-long success. A case manager should also be able to make decisions on behalf of the client based on this information as well as consider possible alternatives that might improve his/her quality of life while still meeting basic needs (such as food).


Providers with successful SDOH management programs are better equipped to deliver high-quality, value-based care.


The healthcare system is moving towards an era of “precision medicine” – which will provide better care for patients and more value for the dollar. But to get there, we need to start thinking differently about how we deliver care today and in the future. By using technology to monitor and manage chronic disease, healthcare providers can improve patient outcomes while lowering costs. SDOH is often overlooked by healthcare professionals, policymakers, and community members. Yet it plays a significant role in health outcomes and quality of life.



The aim of the chronic care management program is to improve the health of older adults and their ability to live independently. While it does not have a single focus, CCM programs have incorporated SDOH into their services so that they can address health concerns that may arise later in life or as part of other conditions such as diabetes or arthritis. CCM's role has been recognized by Medicare an

d Medicaid as well as private insurers who want to support this effort at reducing overall costs while ensuring appropriate care for those suffering from chronic illness


As the healthcare landscape continues to evolve, it’s more important than ever that we work together as a community to ensure all patients receive the best care possible. Our team recognizes that social determinants of health are a key factor in this effort, and we are committed to providing solutions for every patient who walks through our doors. We hope this article has given you an idea of how your role might be affected by these complex issues. For more information about Chronic Care Management Program or other services provided by our team at Proficient Health Care, please visit us online or call 601.863.0258 or email us at ccm@proficienthsa.com.







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