Case manager at workFiled Under: Social Determinants of Health

Solving the Social Determinants of Health during the Holiday Season

Case manager at work

In our work to enhance the health of pregnant moms, new mothers or caregivers, and the newly born, we are reminded that health is more than a description of our physical state. Health is also a reflection of how we live. Where we were born and how we learn, work, shop, play, and age affect our quality of life. These health influencers are called the Social Determinants – or “drivers”— of Health (SDoH).

SDoH issues affect what we eat, our sense of security, social engagement, and family support. They enhance or degrade our well-being by affecting access to healthcare, fresh food, and a living space free from toxins. Solving for the broad array of SDoH is critical to maintaining a continuity of care from pregnancy to hospital discharge and beyond – especially in Medicaid populations.

In 2021, our maternity case managers expanded our SDoH mission by working with pregnant women much earlier in the reproductive cycle – before a potential NICU admission occurs. When expectant mothers have access to better nutrition, stable housing, and access to maternity support, the positive impact BEFORE their baby is born is immeasurable.

Our case managers report that the pandemic has played a significant role in driving SDoH. Today, expectant women and new caregivers are facing the twin challenges of inflation and loneliness from the pandemic. Harvard researchers have found young people have been hit particularly hard:

“Many young people who reported serious loneliness also said they felt as if no one ‘genuinely cared’ about them,” said Richard Weissbourd, lead researcher. The report recommends that “eliminating loneliness requires a robust social infrastructure.” 1

ProgenyHealth’s program of outreach is part of that social infrastructure. Here is how we help:

  • David was born at 36 weeks with neonatal abstinence syndrome (NAS) to a mom who tested positive for THC, opiates, and methadone. Dave had not received any prenatal care.
    • ProgenyHealth’s CM monitored Lizzie’s participation in her Medication-Assisted Treatment (MAT) program. The CM also counseled Lizzie about breastfeeding options and helped her procure a breast pump, car seat, and crib. Additionally, the CM helped Lizzie obtain lactation support, primary care for David, and arrange transportation and appointments to her postpartum care and treatment program.
  • Robert was admitted to the NICU for respiratory distress before being discharged home with his single mom, Mary who needed financial and housing assistance.
    • ProgenyHealth’s CM engaged with Mary before Robert’s discharge and educated her on feeding, developmental milestones, what to do when something doesn’t seem right, and how to access community resources. Mary indicated that she needed assistance with housing. The CM consulted with a ProgenyHealth social worker who helped Mary access the resources and support she needed. ProgenyHealth also helped Mary locate a work/study program that included financial assistance for Robert’s childcare.
  • Lorie was born at 40 weeks with NAS and was treated with morphine for her withdrawal. She required 26 days in the NICU.
    • ProgenyHealth helped Lorie’s mom, Jill find addiction support, including smoking cessation and a new MAT. ProgenyHealth’s social worker researched behavioral health resources, checked the health plan formulary, and shared the information with Jill. To encourage Jill to take Lorie to all well-visit checkups, the CM also linked Jill with the health plan’s health and wellness rewards program, which provided incentives for these healthy behaviors.
  • Lucy was discharged from the NICU to a home where the electricity had been shut off, food spoiled, and a mom with postpartum depression.
    • The ProgenyHealth CM decided that Lucy should go to the ER immediately. The mom agreed. The CM also consulted with the ER social worker and arranged for a primary care visit. ProgenyHealth arranged for emergency lodging, food, power restoration, and baby supplies. As part of follow-up support, the CM arranged behavioral help for postpartum depression and arranged support from a social worker.

We also give special thanks to the Community Based Organizations (CBOs) who partner with us to help address these issues. Every day, our Case Managers tap into our extensive national database of CBOs to find solutions for new moms, caregivers, and families.

Check your state’s department of health and human services website for a list of organizations in your area that can use your support during the holidays – from meal preparation and delivery and cold weather clothing drives to charitable donations.