Across the spectrum of health and human services, social determinants of health have rightfully gained more attention as the influences and environmental factors that impact health and quality of life, including outcomes and risk factors. They include poverty and economic stability, the neighborhood in which one lives, education, and access to health care.

Becoming familiar with the social determinants of health is imperative for case managers as we advocate for clients receiving case management services and their families/support systems. As Fink-Samnick (2018) observed,

Those persons and communities impacted most by the SDH [social determinants of health] comprise every case management practice setting. These clients can be among the most vulnerable and disenfranchised members of society, which can easily engender biases on the part of the interprofessional workforce. (p. 107)

As case managers, we cannot allow ourselves to make judgments or assumptions based only on what we see, without understanding the social, environmental, and economic factors that can undermine health and wellness.

Statistics tell a sobering story, as a few examples attest. The U.S. Census Bureau reported the official poverty rate for the United States of 11.4% in 2020, up 1.0 percentage point from the prior year; after five consecutive annual declines in the poverty rate, 2020 saw the first increase (Shrider et al., 2021). Approximately one in 10 people in the United States does not have health insurance and therefore is less likely to have a primary care provider. In addition, they may not be able to pay for health care services and medications (U.S. Department of Health and Human Services, n.d.). People with low levels of literacy are also likely to have difficulties understanding prescription labels and doctors' instructions, which are components of health literacy (HealthyPeople.gov, 2020). But statistics are not the full extent of the story. Social determinants of health are best understood in the context of the lives of real people.

For example, we cannot look at people who, on the surface, appear to have financial resources and assume that permanent housing would never be an issue for them. It may be that death, divorce, or another loss resulted in them being unable to keep their homes. In contrast, we may see someone who is undomiciled and make assumptions for why this person lives on the street, perhaps due to addiction or mental health issues. As advocates, we must see the whole person with unique needs, beliefs, choices, and circumstances.

A Man Named "Joe"

Although there may be some similarities across certain populations with shared demographics, each individual has a unique story. I came to understand this, personally and profoundly, about 15 years ago while working in a major metropolitan hospital center. Among the people who accessed care at this hospital were many uninsured patients and a significant portion of them were also undomiciled. A man we will call "Joe" was among them. Elderly and in poor health, Joe was homeless by choice. Because of his disease state and lack of housing, he became a high utilizer of emergency department services and had to be hospitalized frequently. While admitted, Joe was a patient in my unit.

A social worker colleague and I spoke with Joe to get a better understanding of his living circumstances. Clearly, the social determinants we could observe-homelessness and difficulties obtaining prescriptions and accessing ongoing care-impacted his health and made it more challenging to care for him. But there was another factor that we could not know merely by observing; to learn more, we first had to establish rapport.

Each time we asked Joe about staying in a shelter and offered to investigate available facilities for him, he refused. When we asked him why, Joe did not have an answer right away. Finally, he told us, "I don't deserve it."

He only shared a few details of his story, but those were enough for us to gain a more complete picture of Joe's life. He had been imprisoned for decades in a maximum-security prison. "I did very bad things," he told us. After his release, Joe chose to be undomiciled because he believed he did not deserve anything else. Although he was elderly and in poor health, his choice was to spend his days and nights on the street.

Through our interactions, I learned more about Joe's current circumstances and choices. He did not suffer from food insecurity; he knew the location of all the soup kitchens in the area and readily availed himself of that help. He also demonstrated the capacity to make his own decisions. Therefore, I was ethically and professionally obligated to respect his autonomy and his right to self-determination.

Autonomy is a key part of the underlying values of case management practice, as defined by the Code of Professional Conduct from the Commission for Case Manager Certification (CCMC, 2015). As the Code states: "Board-Certified Case Managers (CCMs) understand that case management is guided by the ethical principles of autonomy, beneficence, nonmaleficence, justice, and fidelity" (p. 3). Even when it is difficult, even when we would secretly wish for our clients to make different choices, autonomy and other ethical principles prevent us from interfering or trying to influence our clients' decisions. This was yet another lesson that I learned anew from providing care for Joe over his many visits to the hospital.

In addition, Joe gave me a deeper perspective on the mission of case management in the context of the "5 rights." These rights are familiar to many of us in case management and our professional disciplines such as nursing or social work. The way I like to express them from a case management perspective is "the right care, at the right time, in the right place, with the right provider, at the right cost." It is not the size, scope, or duration of the intervention that matters; it is the "rightness" of the act itself. We provide access to care and resources according to our clients' goals, priorities, and values.

While respecting Joe's decision to remain undomiciled, I felt we had built sufficient rapport over time to ask what we could do for him. He thought for a moment and then said, "You can give me a pair of socks." And so I got him socks-one of the pieces of clothing that cannot be donated unless they are brand new. For the undomiciled and others exposed to the elements, socks are often the one item they need the most.

After that, I always kept a package of socks in my desk drawer to give to Joe whenever he came to the emergency department or was admitted for a few days. I can recall colleagues seeing me in the hallway and saying, "Your friend is here," and I would tell them where I kept the socks. In the context of Joe's goals and what he needed, given his social determinants of health, those socks helped improve his well-being and kept him connected with a health care community.

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