Effective Care Coordination Addresses All Determinants of Health
There are three principal factors that influence health outcomes. These include the physical, behavioral, and social determinants of health. Healthcare systems have traditionally focused on the physical and behavioral aspects of health, while the social determinants have been a significant driver of higher costs of care and reduced health outcomes. According to the Kaiser Family Foundation: Health and well-being are determined by the interaction of individual genetics; personal behaviors; social and environmental factors; and health care services. And, “Social determinants of health are the conditions in which people are born, grow, live, work and age. They include factors like socioeconomic status, education, neighborhood, and physical environment, employment, and social support networks, as well as access to health care.” It has been estimated (reference = county health rankings) that a person’s physical environment; their social and economic factors; and personal health behaviors account for up to 80% of all health outcomes.
Care coordination services help individuals navigate complex health care systems and foster and support engagement and activation for improved health behaviors and outcomes. This is achieved through the establishment of person-centered treatment plans and coordination among systems of care to support positive health outcomes and improved well-being.
Comprehensive care coordination requires the engagement of an individual across the full spectrum of their physical, behavioral, and social determinants of health. For too long, the key elements of social determinants have been neglected or ignored. Effective care coordination assesses the impact of all social determinants of health, including:
- An individual’s social and economic stability – including education, employment, income, and family and other social supports;
- Their physical environment – including housing, transportation, food instability, and air and water quality;
- Their health behaviors – including diet and exercise, tobacco alcohol and drug use, and sexual behaviors; and,
- Clinical care – including access to care and the quality of that care.
Effective care coordination identifies at-risk individuals, establishes person-centered care plans, and integrates social, behavioral and physical health services. The goal is to provide the resources for individuals to improve their health behaviors and overcome any physical behavioral, and social determinants that impede the realization of positive health outcomes. Key elements of these services include the use of established care coordination pathways that support the assessment of health and social risks, and determine the best approaches to achieve improved health outcomes. These include an individual’s health behaviors, and the integration of physical and social services to overcome any barriers to improved health.