Case Management Focus: What If?

20 Nov, 2023 Anne Llewellyn


Sarasota, FL ( -- Case managers are problem solvers. When they see a problem, they brainstorm with the team to think of ways to address the challenges they are seeing and develop a plan to address those challenges. It starts with the words “What If”. 

Recently, I read a post from Dr. Jennifer Christian, the Chair of the Alliance for Bridging Health & Work on a listserv she moderates. She shared a new project Boston College developed to address Social Determinants of Health for patients in their primary health clinic. I thought the program was genius, so I wanted to share it in this week's article.    

Here is the story!  

Doctors are challenged with how to meet their patient’s needs. One doctor was following a patient for a few years in the Primary Healthcare Clinic. The doctor was able to treat the patients to help them deal with their healthcare issues – but was at a loss to help them deal with the social issues that impacted their lives.  

In one of the meetings with his leadership team, he brought up the problems he was seeing. Many ideas were suggested, but nothing the team thought they could do. It was then that one person on the team said: “What If we started a program to address patients at high-risk patients from their primary care clinics.” We already have an assessment process that all patients underwent when they came for visits to the Primary Health Clinic. Part of the assessment was a social determinants of health screener — a tool to screen for, among other things, challenges people had with securing food, jobs, and housing insecurity. The idea was to use this tool to identify patients and risk and start to put a plan together to address the issues.  

As most know, SDoH are challenges people face that impact their lives, mentally, physically, socially and financially . Examples include nutrition, housing, and work status. The lower the scores, the more challenges people have and these challenges impact their health.  

Today, insurance companies are reimbursing providers to address SDoH challenges and try to resolve them as they realize that to help someone stay healthy, they have basic needs met, and if they are not met – the person's health status will decline.  

The project called for patients who marked joblessness on the screener and who were interested in becoming eligible for the fellowship program where they would be enrolled in 12 weeks of career training at the YMCA, learning medical terminology, how to navigate public and private payers, and practicing through simulations, as well as participating in on-site training on the systems and technical skills needed to succeed in the role. Those who completed this program were offered interviews and hired to full-time jobs with benefits, ongoing training opportunities, and career mobility at the  Boston Medical Center.  

In addition to helping people address SDoH, the project also filled gaps in staffing as those who graduated from the program were offered a job with the health system. It was a win-win for patients and the organization.  

What if this type of program was spread over the country? How could it change our communities, the people who live in them, and the organizations that serve them?  

What innovative programs has your organization put together to address the challenges you see in your communities/patients? Email me at allewellyn48@gmail, and I will share it in a future article.  


Here is an article on the project:  

Social Determinants of Health:,higher%20risk%20of%20premature%20death  

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    About The Author

    • Anne Llewellyn

      Anne Llewellyn is a registered nurse with over forty years of experience in critical care, risk management, case management, patient advocacy, healthcare publications and training and development. Anne has been a leader in the area of Patient Advocacy since 2010. She was a Founding member of the Patient Advocate Certification Board and is currently serving on the National Association of Health Care Advocacy. Anne writes a weekly Blog, Nurse Advocate to share stories and events that will educate and empower people be better prepared when they enter the healthcare system.

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