Chronic Care Management May Be the Key to Equalizing Care and Outcomes

Healthcare providers have long known that social determinants of health (SDOH) impact patients with chronic and complex diseases in ways that can’t be understated. The challenge lies in identifying these factors, which can range from health literacy to food insecurity.

The COVID-19 pandemic is an excellent example of a situation in which people were disproportionately affected. This was the case with both mental health (anxiety, depression, worries about an inability to make enough money) and physical health (food insufficiency, leaving a sickness unchecked). As an example, regular screenings for a range of cancers not only plunged during the pandemic but now that the pandemic has receded, physicians are noting a sharp increase in visits from patients with more advanced cancers.

The crux of chronic care is being able to give it to those who need it.

The problem with delivering chronic care

The crux of chronic care is being able to give it to those who need it, but there are issues with putting this into practice:

  • How can the people who need it be identified more effectively?
  • How can necessary care be given to more patients, especially in times like the pandemic?
  • How can the process of triaging patients be more comprehensive?

The answer to these questions seems to lie in being able to take a systemic approach to not only identifying but keeping SDOH in mind as part of a chronic care management program, acting as an equalizer when caring for patients with vastly different SDOH.


SDOH identification and response

There are 3 elements to consider when creating the framework for SDOH identification and response.

  1. Discussions should be navigated with care

There must be a clinical framework that allows team members to get the information that they need from patients without using buzzwords or phrases that can cause embarrassment or offense.

Care navigators and medical assistants can ask questions like: “what have you been eating recently? How do you like to stay active?” to assess patients’ diet and activity levels.

These questions and their answers can foster the kinds of conversations where professionals can get information like unexplained weight loss or other red flags which would need in-person follow-ups.

Condition-specific questions which any patient can understand will also help bridge any health-literacy gaps. These are usually yes/no questions such as: “have you been urinating more frequently?” and “have you had any lower back pain?”.

Additionally, sometimes the right way to approach discussions depends more on who is involved in the discussion than on what’s being discussed. Having a team member that the patient knows or might be more comfortable with can often be the best (or only) way forward.


Patients who need follow-ups should be prioritized.


  1. Patients who need in-person follow-ups should be prioritized

An SDOH-discovery-and-response-based framework gives healthcare providers a way to better understand which patients to prioritize and the confidence to know that they’ve made the right choice when they do so.

Software solutions that incorporate this framework also can use clinical questions and protocols to give healthcare providers the correct and best next steps to take.


  1. Lessons learned should be lessons shared

There should be forums for key providers, medical assistants, and care navigators to share and discuss their tips, findings, and experiences with SDOH-discovery-and-response-based care. Not only does this facilitate more learning, but it fosters trust between healthcare professionals and normalizes this approach to healthcare.


Chronic care management with SDOH discovery and response as a framework means that patients’ unique needs can be better understood and responded to, bringing better access and equity to healthcare and health outcomes.



To learn more about how Complex Care Plan from Coalese Health can help, contact us>>



Lee, S. (2022, April 23). Contributor: How chronic care management could be the great equalizer for care. AJMC.