What is Social Care?
In the context of the US healthcare system, social care is the provision of health and human services to address social risk factors. The World Health Organization is one of the key organizations that spearheaded efforts to understand how upstream socio-economic circumstances impact a population’s health (“Social Determinants Of Health” 2021). From this research, the term Social Determinants of Health (SDoH) was born (“Social Determinants Of Health” 2021).
Since the inception of SDoH, health organizations have been incorporating social care coordination into their daily operations (when appropriate) to minimize adverse health events. (A 2016 study reveals that hospitalizations increase at the end of the month when food assistance runs out (“Connecting Food-Insecure Individuals To Resources” 2021).)
Community-based organizations are the main providers of social care. These entities are usually local non-profits and agencies. However, larger organizations such as the U.S. Department of Agriculture also offer social programs and services to people in need.
What is Social Care Coordination?
Healthcare providers frequently use the term care coordination. The Agency for Healthcare Research and Quality (AHRQ) defines care coordination as, “… the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care” (Mitchell and Shortell 2000).
Healthcare organizations are at the forefront of social care coordination. A home-insecure individual, for instance, has negative health repercussions from being unsheltered. The healthcare provider that is treating this individual needs to address the social issue to prevent any more ailments that stem from it. However, the healthcare provider is not equipped or trained to perform this task. In this scenario, the healthcare provider either refers the patient to a social service agency (or housing provider) or to a social worker that is part of their team.
Social care providers gather pertinent documentation and information to facilitate the process of addressing social needs. Large social organizations (such as the USDA and their SNAP program) and even small, local organizations (such as a local faith-based ministry) may require information on a person’s circumstance to provide care. The complexity of the system can be too difficult to navigate for individuals who have multiple physical ailments and/or psychosocial needs.
Why Is It Important for Home Health Patients to Receive Social Care?
Social care is particularly important in the context of home health as most home health patients are considered “home-bound”. A doctor—(and in some states nurse practitioners and physician assistants)—must certify that a person is confined to the home (“Home Health Services Coverage” 2021). Approximately two million older adults aged 65 and older in the United States meet the criteria for being homebound (Ankuda et al. 2021). Homebound older adults already experience challenges to living in their home independently. They especially face challenges to obtaining resources outside of the home.
As Americans age and live longer, there is an increase in comorbid chronic conditions, such as diabetes or dementia. Multiple chronic illnesses also affect a person’s functional abilities, such as difficulty with mobility and managing one’s household.
Home health agencies have interdisciplinary teams of professionals, including nurses, physical therapists, occupational therapists, speech-language pathologists, and social workers. Social workers coordinate social care directly in the patient’s home lessening the burden of finding resources. This extremely important function of home health reduces the risk of adverse health events that originate from social needs.
Click here to find out more about SSRx’s home health model and social care coordination feature.
Ankuda, Claire K., Mohammed Husain, Evan Bollens‐Lund, Bruce Leff, Christine S. Ritchie, Shelley H. Liu, and Katherine A. Ornstein. 2021. “The Dynamics Of Being Homebound Over Time: A Prospective Study Of Medicare Beneficiaries, 2012–2018”. Journal Of The American Geriatrics Society 69 (6): 1609-1616. doi:10.1111/jgs.17086.
“Connecting Food-Insecure Individuals To Resources”. 2021. Delivering Community Benefit: Healthy Food Playbook. https://foodcommunitybenefit.noharm.org/resources/implementation-strategy/connecting-food-insecure-individuals-resources
“Home Health Services Coverage”. 2021. Medicare. https://www.medicare.gov/coverage/home-health-services
Mitchell, Shannon M., and Stephen M. Shortell. 2000. “The Governance And Management Of Effective Community Health Partnerships: A Typology For Research, Policy, And Practice”. The Milbank Quarterly 78 (2): 241-289. doi:10.1111/1468-0009.00170.
“Social Determinants Of Health”. 2021. World Health Organization. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1.[/vc_column_text][/vc_column][/vc_row]