Ask any seasoned care coordinator what gets in the way of a member’s health, and they’ll give you a list that goes way beyond the clinical. Transportation. Food insecurity. Unstable housing. The fear of taking time off work for an appointment that might cost more than they can afford.
We’ve known for decades that social determinants account for a significant portion of health outcomes — some researchers estimate as much as 80 percent. And yet, healthcare systems have historically been designed to treat what happens inside the exam room, not the conditions people return home to.
At SCCP, our ecological model of care coordination was built with this reality in mind from the start. When our navigators connect with a member, they’re not just checking off clinical boxes. They’re asking the deeper questions: Do you have reliable transportation to your appointments? Do you have enough food at home? Is your living situation stable?
These aren’t intrusive questions — they’re the gateway to actually helping. And when we can connect members to the right social services alongside their clinical care, the results speak for themselves. Better adherence. Fewer emergency visits. Members who feel seen and supported, not just managed.
As health equity remains a priority across Medicaid and Medicare Advantage programs, closing the gap between clinical care and social support isn’t optional anymore. It’s the work.
References:
Braveman, P., & Gottlieb, L. (2014). The Social Determinants of Health: It’s Time to Consider the Causes of the Causes. Public Health Reports, 129(Suppl 2), 19–31.
CMS. (2024). Health-Related Social Needs Screening and Intervention — Medicaid and CHIP Policy Academy.