Improving patient well‐being in the United States through care coordination interventions informed by social determinants of health

Abstract

Health and well‐being are promoted when primary care teams partner with patients and provide care coordination to mitigate risks and promote optimal health. Identification of patients for care coordination is typically based on claim‐driven risk assessments. Evidence shows that social determinants of health (SDOH) drive risk for adverse health outcomes but are omitted from existing risk tools. Missed opportunities for care coordination contribute to increased healthcare costs, poorer health outcomes and reduced patient well‐being. To address the gap of risk‐informed care coordination that includes SDOH, the aim of this project was to implement process improvement of a system's care coordination program through refined patient selection and customised engagement in intensive care coordination. A non‐randomised care coordination quality improvement project was conducted at a community health centre in 2020. Inclusion criteria (i.e. presence of risk attribution score, SDOH questionnaire completed) resulted in 540 patients being offered care coordination services; Patients having at least one month of care coordination were included in the analysis (N = 216). Analysis included the 216 patients that chose participation and the 324 patients that maintained usual care. Descriptive statistics were generated to distinguish patient demographics, frequency of care coordination contact, and specific SDOH insecurities for both the study and comparison groups. Paired t‐tests were incorporated to evaluate statistical significance of the intervention group. Impact on well‐being, SDOH barriers, appointment adherence and health outcomes were assessed in both conditions. Intervention condition patients reported improvement in well‐being [feeling anxious (t = 4.051; p < 0.000)] and reduced SDOH barriers [food access (t = 4.662; p < 0.000); housing (t = 2.203; p = 0.008)] that were significantly different from the usual care condition in the expected directions. Care coordination based on factors including SDOH risks shows promise in improving patient well‐being. Future research should refine this approach for comprehensive risk assessment to intervene and support patient health and well‐being.

Adverse Social Determinants of Health and Gaps in Care Coordination Among Children

“…There is existing literature confirming the association between SDoH and gaps in CC primarily for CSHCN (Miller et al, 2019; Mirza et al, 2022; Singer & Porta, 2022). Our study adds to the literature in that it shows SDoH is associated with CC gaps among non-CSHCN children, a finding that has not been widely reported.…”

Addressing Social Determinants of Health

“…Benefits achieved through care coordination include reduced hospital stays, lower cost of inpatient care, reduced usage of inpatient services, and higher satisfaction for individuals (Berry et al, 2013). Because of its comprehensive nature, care coordination is also being recognized as an effective strategy in identifying and addressing SDOH (Francis et al, 2018; Singer & Porta, 2022). For case managers, this is both an inspiration and a call to greater awareness and action.…”

Practice Perspectives on Care Coordination in Rural Settings

“…A review of care coordination models with social services identified variability in target populations and services (Albertson et al, 2021). Although early results of enhanced care coordination suggest promise for improved patient well-being and reductions in key social determinants of health (SDoH) barriers (Bradley et al, 2018; Singer & Porta, 2022), this field is still emerging and significant literature gaps remain related to rural settings. Developing a more contextually relevant understanding of the rural care coordination setting is critical.…”