Social Work-Led Care Management for Adults with Multiple Chronic Conditions

Background and Purpose: People in the United States with multiple chronic conditions (MCCs) continue to have unmet behavioral health and social needs that contribute to poor health and healthcare inequities. Good social care management is key to addressing the social needs of patients with MCCs. With the growth in value-based care, healthcare organizations spanning the continuum of care from primary to inpatient to post-acute have implemented care management programs to address social needs as a strategy to reduce unnecessary hospitalizations and emergency department visits. Despite expertise in social care, there is limited research looking at social work-led care management models and the role of social workers (SWs) and community health workers (CHWs) in providing this care. We partnered with a large national primary and specialty care practice serving Medicare beneficiaries with MCCs to evaluate the implementation of care management that included SWs trained on the Center for Health and Social Care (CHaSCI) model and community health workers (CHWs) also trained by CHaSCI. The objective of this presentation is (1) to describe the demographic and health characteristics of patients who were referred for care management services and (2) compare care management contact for patients who received care management services from SWs only, CHWs only, and those who received services from both SWs and CHWs.

Methods: The study was designed using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. We used a retrospective analysis of data from all patients that met inclusion criteria during the three-month enrollment period of 7/1/2021 – 9/30/2022. The inclusion criteria were: 1) a patient must be a member with the practice for 6+ months prior to the enrollment period; 2) the patient was referred for care management services during the enrollment period; and 3) the patient remained a member at the practice for 6+ months after referral for care management.

Results: In total, N=9,722 patients from 102 clinics located across the Eastern, Midwestern, and Southern United States were included in the sample. The mean age of enrolled patients was 68.3 years-old and the majority were female and were Medicare beneficiaries. While not everyone had Hierarchical Condition Categories (HCC) listed, approximately 25% of the sample had 6+ listed. The most prevalent HCC conditions were: immunological, mental health/substance use, endocrine, and cardiovascular. Of the sites where both SW and CHW services were available, patients with CHW only contacts were significantly more likely to have a serious health status and report concerns related to food access and housing. Whereas patients with SW only contacts were significantly more likely to have a very serious health status and report concerns related to substance use.

Conclusions and Implications: It is important to better understand who is getting referred for care management and who is providing the services in order to determine where the service gaps are and how best to address them. This project contributes to the literature on care management as well as provides information about the patients SWs and CHWs engage with.