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How can you address social determinants of health in service improvement initiatives?

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Social determinants of health (SDH) are the conditions in which people are born, grow, live, work and age that affect their health and well-being. As a case manager, you may encounter clients who face challenges related to SDH, such as poverty, discrimination, lack of access to quality care, education, housing, food, transportation and social support. How can you address these factors in your service improvement initiatives? Here are some strategies to consider.

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1 Assess SDH needs

The first step is to identify and assess the SDH needs of your clients and the communities you serve. You can use various tools and methods to collect and analyze data on SDH, such as surveys, interviews, focus groups, community mapping, social network analysis and health equity impact assessment. These can help you understand the strengths, gaps, barriers and opportunities for improving the health and social outcomes of your clients.

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2 Engage stakeholders

The second step is to engage and collaborate with stakeholders who can help you address SDH. These may include your clients, their families and caregivers, other service providers, community organizations, policy makers, funders and researchers. You can use different approaches to involve them in your service improvement initiatives, such as co-design, partnership, advocacy, consultation and feedback. These can help you build trust, alignment, commitment and accountability for addressing SDH.

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Sureen Hasan, MPH

Health Promotion | Mental health | Diversity & Inclusion
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Collaborate with local organizations, government agencies, and non-profits working on social determinants of health. Building partnerships can enhance the range of resources and support available to clients.

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3 Implement interventions

The third step is to implement interventions that address SDH in your service delivery. You can use various models and frameworks to guide your interventions, such as the social ecological model, the chronic care model, the population health approach and the social justice approach. These can help you design and deliver services that are holistic, person-centered, culturally responsive, evidence-based and equitable. You can also use quality improvement methods, such as Plan-Do-Study-Act cycles, to test and refine your interventions.

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Sureen Hasan, MPH

Health Promotion | Mental health | Diversity & Inclusion
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Promote cultural competency among staff to ensure services are sensitive to the unique needs and experiences of different cultural groups. Tailor services to be culturally relevant and respectful.

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4 Evaluate outcomes

The fourth step is to evaluate the outcomes and impacts of your interventions on SDH. You can use various indicators and measures to monitor and evaluate your interventions, such as health status, quality of life, satisfaction, access, utilization, cost-effectiveness and health equity. You can also use different methods to collect and analyze data, such as quantitative, qualitative and mixed methods. These can help you demonstrate the value and effectiveness of your interventions and identify areas for improvement.

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Sureen Hasan, MPH

Health Promotion | Mental health | Diversity & Inclusion
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Collect and analyze data related to social determinants of health within the community. Use this information to continuously assess the impact of services and identify areas for improvement to better address these determinants.

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5 Share learnings

The fifth step is to share your learnings and best practices with other case managers and stakeholders who are interested in addressing SDH. You can use different channels and formats to disseminate your learnings, such as reports, presentations, publications, webinars, podcasts and social media. These can help you increase the awareness, knowledge and skills of others who want to address SDH in their service improvement initiatives.

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6 Adapt to changes

The sixth step is to adapt to the changes and challenges that may arise in addressing SDH. You can use various tools and techniques to scan and respond to the external and internal factors that may affect your interventions, such as environmental, political, economic, social, technological, legal and ethical factors. These can help you anticipate, prevent or mitigate the risks and uncertainties that may hinder your efforts to address SDH.

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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?

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How can you address social determinants of health in service improvement initiatives?

1

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3

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1 Assess SDH needs

2 Engage stakeholders

3 Implement interventions

4 Evaluate outcomes

5 Share learnings

6 Adapt to changes

7 Here’s what else to consider

Case Management

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How can you address social determinants of health in service improvement initiatives?

1

2

3

4

5

6

7

1 Assess SDH needs

2 Engage stakeholders

3 Implement interventions

4 Evaluate outcomes

5 Share learnings

6 Adapt to changes

7 Here’s what else to consider

Case Management

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