There is a saying that we meet our patients where they are. But as nurse case managers, we meet our patients where they are and work to help them find the resources they need to move forward.

As part of the nurse case managers’ assessment, we are charged with identifying those at risk, addressing barriers to care, and coordinating resources that improve patients’ overall well-being.

Social determinants of health (SDOH) are the non-medical factors that shape a person’s health outcomes and overall well-being. SDOH encompass the conditions in which people are born, grow, live, work, and age, as well as the broader systems and forces that influence those conditions. Here is an overview of SDOH.

• Economic Stability: Income level, employment status, and financial security all affect access to healthcare, nutritious food, and safe housing.
• Education Access and Quality: Literacy, educational attainment, and school quality influence health literacy and job opportunities.
• Healthcare Access and Quality: Availability of healthcare services, insurance coverage, and cultural competence of providers impact health outcomes.
• Neighborhood and Built Environment: Safe housing, transportation options, access to healthy foods, and exposure to environmental hazards play a role.
• Social and Community Context: Social support networks, discrimination, and civic participation affect mental and physical health.

Let’s Look at Key Strategies Case Managers Use to Address SDOH

• Comprehensive Assessment
  Case managers begin by evaluating a patient’s environment, income, education, housing, transportation, and social support. This helps identify non-medical factors that may affect health outcomes.
• Resource Navigation
  Nurse case managers connect patients to community services, including food banks, housing assistance, transportation programs, and job training.
• Care Coordination
  Case managers collaborate with the broader healthcare team —providers, social workers, and community agencies — to ensure patients receive holistic care. This includes mental health services, substance use support, and chronic disease management as needed.
• Advocacy and Education
  Nurse case managers advocate for patients within healthcare systems and educate them about available benefits and services. We ensure patients are seen and heard. Doing so empowers people to make informed decisions and engage in their care plans.
• Monitoring and Follow-Up
  Ongoing communication ensures that interventions are effective and that patients continue to receive support. Case managers track progress and proactively adjust plans to catch issues early and avoid regressions.

I hope this article reminds you to meet your patients where they are and help them move forward to reach their highest potential.

Have a good week!