How do you manage complex cases with many social determinants?

Additionally, maintaining ongoing communication and collaboration with the client's care team and community resources is pivotal for effective case management, ensuring a holistic approach to addressing social determinants of health

In assessing a client strengths and needs, a case manager can get a sense of how to help the client prioritize goals. For example, a client may have a need of housing and employment; however, in examining their strengths, you may realize that they have a connection with someone in a job that they would like to apply with. Therefore, in this example, the goal of housing may be a more pressing priority, while the goal of employment may be more secondary and may require more follow up from the case manager.

SImply put - Managing complex cases with multiple social determinants requires a holistic approach: Thoroughly understand the client's social factors. Work with a diverse team when necessary. Respect and tailor to the client's culture. Empower clients to use their strengths. Set achievable, prioritized goals. Connect clients to community resources. Address systemic barriers as needed. Develop crisis plans for acute challenges. Continuously assess and adjust. Self-Care: Prioritize self-care to avoid burnout. This approach ensures comprehensive support for clients with complex cases and diverse social determinants.

Use motivational interviewing and explore/discuss Maslow’s hierarchy of needs alongside clients to solicit sufficient information which will empower social workers and case managers to best prioritize SDOH. Find multifaceted resources that address more than one, ideally all, applicable SDOH to minimize providers. Assess behavioral change and be sure to analyze each case from an ecological perspective,

Be mindful that every situation is unique, and what YOUR goals may have been for the client do not always correspond to the client's own identified needs. Incorporate standard SDOH assessment tools, and establish a good rapport. Developing a sense of trust and respect with the client can allow them to feel comfortable in collaborating to achieve optimal oitcomes. Client empowerment is an essential component of attaining milestones and ultimately goals.

Remember, the client and family own the care plan, not you. The plan is for their benefit directing support for their life, so they must have the power to decide and direct what is included and what is not.

I start with not using ‘determinants’ they are drivers. Humans have free and society owes it to oppressed people to take responsibility for the systems we have built. Oppression wins as long as we think in deterministic frameworks because it absolves us of responsibility.

In developing the care plan, it's crucial to explore potential barriers that could hinder the client's progress and proactively identify strategies to overcome these obstacles. This proactive problem-solving approach can greatly enhance the plan's effectiveness.

In supporting families through some of the hardest situations, I have learned that the most success comes from motivating people to take control of their outcomes. This means that no matter how much we disagree, or how much tension there is, we need to find a human connection with our clients and motivate them to make the best next choice. People can be guided to find the path forward that is unique to their story. This is no exception for children and teenagers. When youth have a voice in the chaos, they can make big strides. Even the most complex youth served by our systems can succeed when supported and empowered by their own personal goals and dreams.

Recognize they realism and idealism are two separate things. While we should all reach for the stars we need to recognize that sometimes landing in the clouds is ok. It gets us closer to where we want to be without failing because we want too much at once

Effective coordination in complex cases necessitates a proactive role in resolving any conflicts or discrepancies that may arise within the care team.

Many people have complex needs and/or are involved in large medical systems. Case managers have an important role in facilitating continuity of care and patient advocacy. For example, a client may be seeing two doctors for two different medical concerns; yet, the client is worried that the medication they’re receiving is too much from both. In this instance with client consent, a case manager can help facilitate a conversation between the doctors, share information regarding the medication each of the doctors are prescribing, and empower the client to share their concerns, and what they are experiencing.

Be sure to recognize the small gains as wins. Most issues took long to develop this will need time to resolve. Celebrate the small steps. It may be faster to run but walking will get you there safely

Speaking as an administrative physician with many years of experience as a health plan medical director and consultant, I cannot stress enough how important proper management of complex social determinants of health is. It's really eye-opening to see how much health outcomes improve and health care spending decreases when patient psychosocial challenges are adequately managed.

You can only accomplish what the client will allow you to. Imposing your unwanted ideas will only result in frustration by both parties. Be sure you understand the end goal