From Homelessness to Self-Sufficiency, Case Management-Style Program Works
EXECUTIVE SUMMARY
Social determinants of health increasingly affect the health of patients and the living circumstances of people in poverty. One novel care transition and community case management program seeks to help people improve their physical and mental health through focus on social determinants and poverty re- duction techniques.
Monthly healthcare costs for people with chronic conditions are higher if the person also is diag- nosed with comorbid depression.
Case managers are well positioned to lead the healthcare industry in pioneering responses to so- cial determinants of health.
The Transitions to Success framework is evidence-based and uses a person-centered approach, including motivational interviewing.
Case managers increasingly recognize the importance of addressing social determinants of health among patients across the care continuum, but evidence-based interventions are scarce.
One new program seeks to change this with tactics to address one of the most prevalent social determi- nants of health: Poverty.
A novel care transition and community case management program provides an evidence-based stan- dard of care to treat poverty as an environmentally based and treatable condition, says Marcella Wilson, PhD, chief executive officer and founder of Transition to Success (TTS).
“The foundation for all that we do is to first try to change the understanding of poverty from character flaw to a treatable condition,” Wilson says. “We want to undermine the character flaw mentality and shame, which are rooted in racism and bias.”
Poverty and mental health issues affect a person’s overall physical health and their medical costs. For instance, data show monthly healthcare expenditures for people with chronic conditions are 54% greater if they also are diagnosed with comorbid depression. There is a 67% increase in expenditures if they have both chronic conditions and anxiety.1
“When you think about poverty, it exacerbates all of that,” Wilson says. “The relationship between social determinants of health, poverty, and behavioral health issues is direct and irrefutable. It makes common sense.”
The healthcare industry is leading the world in showing a connection between poverty and disease. It is the first industry to provide coding to those social determinants exposures.
“The care management industry is purposely positioned to pioneer social determinants of health re- sponse,” Wilson says. “Case management organizations like CCMC [Commission for Case Manager Certification] can pioneer incredible improved outcomes as well as significant cost savings related to so- cial determinants of health response.”
This is the upcoming frontier of healthcare, she adds.
NEXT Memphis in Tennessee is a community-based organization that used TTS framework as part of its work with families in crisis.
“TTS is an evidence-based practice, using a person-centered approach that includes motivational inter- viewing, trauma-informed care, and warm handoff,” says Brooke Churchill, care coordinator supervisor with NEXT Memphis.
The approach also addresses adverse childhood experiences (ACE). Care coordinators’ training and knowledge of trauma-informed care and ACE often are important to help people make positive and sus- tainable changes.
Care-coordinating coaches receive more than 20 hours of coaches training, providing them with an over- view, tools, and skills in the framework. One facet of training is education about the different types of poverty, including generational poverty, urban poverty, and rural poverty.
“When we work to help families address barriers and economic insecurities, we’re ultimately helping chil- dren achieve health and educational goals for their future,” Churchill says. “While the child is in the [preschool] classroom, we work with best practices with the teacher.”
Care coordinators help empower parents, and instructional coaches work with teachers at the child care center to enhance their childhood experience for the client.
“Our clients are parents, and we work with them to empower them for healthy and optimal lifestyles for their children,” Churchill says. (See story in this issue about how care coordination helped a client es- cape homelessness.)
The person-centered approach means care coordinators respect parents as the experts in their lives and in the lives of their families. “If that parent is interested in quitting smoking, we’ll provide all the resources and referrals they need to stop,” Churchill says. “Substance use is part of our assessment. We’ve had people come asking for help in that area, but we don’t push referrals on them until they’re ready for that referral.”
Research involving TTS found the model has statistically significant results in improving the social condi- tions in Head Start and at an outpatient Medicaid behavioral health clinic.2
The TTS method offers people the opportunity to coordinate all resources effectively to support their health, including behavioral health. “In one study, we trained master-level clinicians in a Medicaid clinic in Detroit on how to integrate care management, volunteerism, peer mentoring, and financial literacy with their patients,” Wilson says. “In an average length of stay of six visits, they saw improved outcomes at a cost of less than $600.”2
A TTS clinician tool includes a survey that lists 21 different life areas, including food, housing, budgeting, racism/bigotry, parenting skills, and legal issues. Each life area is assessed according to a five-point scale from one, which equals the person living in crisis, to five, which equals the person feeling empow- ered. Three equals safe, two is for those who are vulnerable, and four is for building capacity.3
Here is one example of a life area (safety) and corresponding five-point scale notes:
Score 1 (in crisis): “Home or residence is not safe; immediate level of lethality is extremely high; possible Child Protective Services involvement.”
Score 2 (vulnerable): “Safety threatened; temporary protection available; level of lethality is high.” Score 3 (safe): “Current level of safety minimally adequate; ongoing safety planning essential.” Score 4 (building capacity): “Environment safe; however, future of such uncertain; safety plan- ning important.”
Score 5 (empowered): “Environment apparently safe and stable.”
For each life area, there are listed options for ICD-10-CM codes that can be used for payer reimburse- ment. For example, under the life area of money, in reference to score 1, there is an ICD-10-CM code of Z59.5 for extreme poverty. For people who are scored from two to four, there is the code of Z59.6 for low income. Some life areas, such as drugs/alcohol use and disabilities, need a clinical diagnosis.3
Social determinants of health are tied to significant health risks, such as diabetes, high blood pressure, increased rates of depression, child abuse, child neglect, and domestic violence and crime.
“Make no mistake — exposures to these social determinants, health conditions and social conditions can cause trauma,” Wilson says. “The relationship between social determinants of health and trauma is very evident, but what’s not evident is how we respond to it. That’s where care managers come in.”
Care managers create the connective tissue between healthcare delivery systems that are siloed in their funding. “This is how we’re going to change the nation. No one chooses to be poor,” Wilson explains. “We have the most expensive delivery system in the world at our fingertips, and it’s care managers who bring it together for the health and welfare of our patients.”
REFERENCES
Wilson M. Behavioral health and social determinants connections. Presented at the Commission for Case Manager Certification 2021 Virtual Symposium, Oct. 12-14, 2021.
Francis L, DePriest K, Wilson M, Gross D. Child poverty, toxic stress, and social determinants of health: Screening and care coordination. Online J Issues Nurs 2018;23:2.
Transition to Success Life Area Survey: Clinician Tool (w/ICD-10-CM x-ref) (http://transitiontosuccess.org/). Transition to Success Map of My Dreams. 2021:1-13.