Social Determinants of Health and How They Affect Older Patients

Social Determinants of Health (SDOH) are non-medical factors that influence health outcomes. Per the CDC, they are conditions that people are born into, grow, work, live, or age in, and a wider set of forces and systems that shape the conditions of daily life.

Through broader awareness of the SDOH that affects our patient demographic, our care managers incorporate these issues into their monthly outreach calls with patients to identify areas that might need attention in order to strengthen the capacity of our organization to advance health equity for the patients that we have been entrusted to care for by our practice partners. Our nurses develop relationships with their assigned patients and through motivational interviewing techniques, they identify SDOH and work to improve those situations.

This might involve matching the patient up with a social worker in their community, helping the patient find a new provider in their area, assisting the patient to fill out necessary form for public aid such as Food Stamps, TANF, or meal delivery programs. In some cases, they may even help with finding the patient new housing accommodations that better suit their physical needs.

Economic Stability

Economic Stability refers to the financial resources a person has available to them, from the ability to buy groceries to the ability to pay for their home. Housing is among the top concerns for older adults and can bring about feelings of stress and anxiety that can aggravate chronic conditions such as heart disease, high blood pressure, diabetes, cholesterol, and obesity - just to name a few. By partnering our patients with the appropriate local resources, we can alleviate some of those stressors and give them back a sense of stability.

Education

Understanding their health conditions and how to better manage those chronic conditions is critical to staying healthy. Health literacy is a term used to describe to what degree people understand the necessary medical information needed to make appropriate health decisions. Chronic Care Management lends these patients the extensive experience and knowledge of the nurses that they are speaking to each month and allows them to better understand their conditions and how best to manage them at home. Having 24/7 access to a licensed healthcare provider gives them a sense of security. Our nurses are able to answer their questions and guide them in their daily decisions, which in turn, lowers their healthcare costs and the burden on our emergency rooms across the country.

Social and Community Context

Social isolation and loneliness can lead to major health risks in the older adult community. Social isolation is associated with higher fall risks, higher rates of cognitive decline, and increased risk of heart attack and stroke. Not to mention that social isolation can also lead to depression and other mental health issues. Our nurses encourage the patients to get involved in their community! They look for senior centers and volunteer opportunities to get these patients out of their homes and into their communities where they can participate and socialize, thereby building a sense of belonging and community for them.

Healthcare and Quality

Having the appropriate providers as well as a good support network is vital for the older adult. Family members are usually the primary caregivers, but in cases where family members are not available, our nurses can help these patients partner with the appropriate local resource to help them "age in place" as long as feasible. Our nurses also make sure that these patients keep their scheduled appointments and take their medications as ordered to prevent any exacerbations of their conditions. They provide reminders for vaccinations and preventative measures and tests according to their conditions.

Neighborhood and Built Environment

Our nurses make sure to make the patients aware of resources available in their community to assist with food, transportation, socialization, and sense of community. This might include Meals on Wheels, part-time housekeepers, senior buses or local volunteers that drive seniors to their appointments or to run errands. It could involve helping the patient to set up grocery delivery or signing up for local food banks. Depending on the availability of resources in the area - our nurses can give back a sense of autonomy to these patients that may have lacked in that area before enrolling in the CCM program.