Use of an Integrated Care Management Program to Uncover and Address Social Determinants of Health for Individuals With Lupus

Abstract

Objective We studied patients with systemic lupus erythematosus (SLE) enrolled in a nurse‐led, multihospital, primary care–based integrated care management program (iCMP) for complex patients with chronic conditions to understand whether social determinants of health (SDoH), including food insecurity, housing instability, and financial constraints, were prevalent in this population. Methods The academic hospital‐based iCMP enrolls the top 2% of medically and psychosocially complex patients identified on the basis of clinical complexity health care use, and primary care provider referral. A nurse conducts needs assessments and coordinates care. We reviewed the electronic medical records of enrolled patients with SLE to identify SDoH needs and corresponding actions taken 1 year prior to iCMP enrollment using physicians’ and social workers’ notes, and during enrollment using iCMP team members’ notes. Results Among 69 patients with SLE in the iCMP, in the year prior to enrollment, 57% had documentation of one or more SDoH challenges, compared with 94% during enrollment. iCMP nurses discussed and addressed one or more SDoH issues for 81% of the patients; transportation challenges, medication access, mental health care access, and financial insecurity were the most prevalent. Nurses connected 75% of these patients with related resources and support. Conclusion Although SDoH‐related issues were not used to identify patients for the iCMP, the vast majority of enrolled medically and psychosocially complex patients with SLE had these needs. The iCMP team uncovered and addressed SDoH‐related concerns not documented prior to iCMP participation. Expansion of care management programs like the iCMP would help identify, document, and address these barriers that contribute to disparities in chronic disease care and outcomes.

Healthcare disparities in telemedicine for rheumatology care

“…Among rheumatic disease patients, there is higher morbidity and mortality rates in racial/ ethnic minorities and individuals of lower socioeconomic status [26][27][28]. Importantly, social determinants of health affect quality of care and access that ultimately define health outcomes in this population [29,30]. This finding is of particular concern as appropriate monitoring and reliable use of immune suppressive medications for systemic lupus erythematosus (SLE) can reduce risk of end-stage renal disease and premature coronary artery disease [4,31,32].…”

Disparities in Lupus and the Role of Social Determinants of Health: Current State of Knowledge and Directions for Future Research

“…Increased travel burden was associated with more missed appointments and medication nonadherence, particularly among Black patients with lupus, due to including reliance on caregivers, financial constraints, and physical limitations (70,71). In an integrated care management program, 66% of patients reported concerns about medication access, and 61% about unmet transportation needs (61%) (72). Specialist diagnosis in American Indian/Alaskan Native people with lupus increased the likelihood of quality care indicators, such as having SLE classification criteria documented, being tested for biomarkers of disease activity, and receiving treatment with hydroxychloroquine (73).…”

The Impact of an Integrated Care Management Program on Acute Care Use and Outpatient Appointment Attendance Among High‐Risk Patients With Lupus

“…The addition of an iCMP team–based model to care plans of high‐need, high‐cost patients with SLE mitigates these SDoH factors by connecting patients with additional resources (such as social work support), improving care coordination, and nurturing relationships and trust. For example, our group recently found that among our cohort of patients with SLE enrolled in the iCMP between 2012 and 2019, iCMP nurses addressed at least one SDoH need for 81% of patients in our cohort and connected 75% of patients with additional resources ( 21 ). Of note, the 37% reduction in ED visit rates among patients with SLE enrolled in the iCMP at our institution from 2012 to 2019 is much greater than the 6% reduction in ED visit rates among all patients enrolled in the iCMP at our institution from 2009 to 2014 ( 10 ).…”