Can Remote Patient Monitoring and Chronic Care Management Play a Role in Social Determinants of Health?

What are Social Determinants of Health

Social Determinants of Health (SDOH) is a relatively new term in health care. It is defined by the World Health Organization (WHO) as the circumstances in which people are born, grow, live, work, and age. The social determinants of health determine access and quality of medical care, often referred to as medical social determinants of health. 

Social determinants have a major impact on health outcomes, especially for the most vulnerable populations. Factors such as a patient’s education, income level, age, household environment, and location must be considered when providing treatment. This concept will easily resonate with clinicians, understanding that health outcomes are affected by a patient’s living conditions and access to care. The obstacle is addressing the health and wellbeing of these patients outside the walls of the practice.   

For the electronic health record, the Institute of Medicine (IOM) has recommended that social and behavioral health domains be captured, as they affect health conditions. For example, those facing mental health issues or living alone can be at an increased risk for health conditions and face barriers to medical care.  

Planning discussions around SDOH must include the following: 

  • Prioritization. This requires an assessment of readiness to address proven interventions and a return on investment. It is important to decide which patients will benefit the most and are these patients ready for interventions, and which SDOHs will have the greatest impact on the total population and healthcare expenditures.   
  • Non-medical factors. A medical approach to non-medical factors will lead to additional healthcare services verse more cost-effective and community-based interventions. For example, a physician or social worker may encounter a patient who lost their partner after many years and has no family. They may need someone to visit with them to resolve depression, help ensure they do not develop depression, or just check to make sure they are taking their prescribed medication.  
  • Deciding what data should be collected. The purpose of data collection must be determined. Discussions around the comprehensiveness of the data, determining the percentage of individuals that are part of the initiative, how will the data be used, and how to address standardization of this data.
  • Building partnerships. Building multisector partnerships is needed for success, and requires trust for sharing, data, resources, and money.  It will be imperative that trust is built between healthcare organizations, community partners, and government institutions.   

What Can Be Done Now to Address SDOH? 

We are facing ever-increasing poor health outcomes due to the impact of social determinants of health, which includes an aging population that is living longer. Although we may not have a systemized approach at this time, there are some actions healthcare systems and providers can take to address some of the concerns.  

When a provider is meeting with a patient, they can ask questions that address the patient’s environmental and social factors such as their living situation; having transportation to get to places; do they have visitors that come and see them; do they face challenges in taking prescribed medications. This information can assist in assessing the likelihood of a patient having a medical emergency or developing behavioral conditions such as anxiety or depression.  

Remote patient monitoring (RPM) and Chronic Care Management or Chronic Care Coordination (CCM) can help address some of the concerns of SDOH. RPM can assist in the care of those that live in rural areas as well as those who may not have transportation or access to timely healthcare. The program was established by the Centers for Medicare and Medicaid in 2015 and became very popular during the pandemic, allowing providers to receive vital information, meet with their patients outside the office, and get paid for the visit. 

RPM Healthcare takes patient monitoring one step further with care coaching. Care coaches, licensed nurses, partner with patients to ensure at-home readings are taken, helping to prevent medical emergencies. Every patient’s needs are different and having a great nurse care coach ensures that patient-centric care is provided. 

Care coaching is critical for success in CCM (managing individuals who suffer from two or more chronic conditions). Successful CCM programs focus on the assessment of a patient’s SDOH and act on it by providing resources. Many people with Medicare see many specialists and the primary care providers do not always get the full picture of their patient’s health. A CCM care coach is the person who acts as a collection hub and helps providers to navigate the health of their patients. They can also provide education and resources. The care coach becomes the person on the other end of the phone developing a relationship of trust that not only addresses a patient’s medical needs but becomes a vehicle for patients to have social interactions, assist with coordination of care, and listen to challenges the patient may be facing. Care coaches go above and beyond to help patients find the support and resources they need, impacting their lives in a positive way. 

Healthcare companies and providers face a tough road ahead, but by working together and implementing even the smallest of efforts to address the many facets of SDOH, we can help our population and improve the quality of their lives.  

RPM Healthcare and our team of care coaches are here to provide an extension to your practice, improve or maintain patient outcomes and quality indicators, offer support and guidance to your patients, and ease the burden of today’s healthcare challenges.

The above article has been reviewed by Irina Koyfman, DNP, NP-C, RN, Chief Population Health Officer, RPM Healthcare. 

Contact us today to learn how we can help provide better care for your patients and generate more revenue for your practice.