How can you address social determinants in case management?

1 Assess SDOH

The first step to address SDOH in case management is to assess the needs and challenges of your clients in relation to their social and environmental factors. You can use standardized tools, such as the PRAPARE assessment, to collect and document data on SDOH, such as income, housing, education, transportation, food security, social support and safety. You can also use open-ended questions and motivational interviewing techniques to elicit your clients' perspectives and preferences on their SDOH.

2 Collaborate with other providers

The second step to address SDOH in case management is to collaborate with other providers and organizations that can offer services and resources to your clients. You can use a multidisciplinary approach to coordinate care and referrals with primary care providers, behavioral health specialists, social workers, community health workers, legal advocates and other relevant partners. You can also use a shared care plan and a common data platform to communicate and track your clients' progress and outcomes across different settings and sectors.

4 Engage your clients

The fourth step to address SDOH in case management is to engage your clients and build trust and rapport with them. You can use a person-centered and culturally responsive approach to respect your clients' values, beliefs, preferences and goals. You can also use a strengths-based and motivational approach to acknowledge your clients' assets, challenges, successes and opportunities. You can also use a collaborative and supportive approach to involve your clients in decision making, goal setting and action planning.

6 Evaluate your impact

The sixth step to address SDOH in case management is to evaluate your impact and measure your effectiveness. You can use a data-driven and outcome-oriented approach to monitor and document your activities, interventions, referrals and follow-ups. You can also use a quality improvement and feedback-driven approach to assess your performance, identify gaps and challenges, solicit input from your clients and stakeholders, and implement changes and improvements.

7 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?