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Partnering with iCare to Address Social Determinants of Health


April 27, 2021

Traditional efforts to improve health in the U.S. have focused heavily on the healthcare system as the primary driver of health-related outcomes. Increasingly, health care providers have begun recognizing the significant impact that social, economic, and environmental factors have on the health and well-being of patients and are acknowledging that attaining health equity requires us to incorporate efforts that address the barriers presented by these social determinants of health (SDoH). According to the CDC,  SDoH are the “conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality of life outcomes and risks” (About Social Determinants of Health (SDOH), 2020).  Using a place-based framework, five key areas of SDoH have been outlined:

  1. Healthcare Access and Quality (access to care, health insurance coverage, health literacy)
  2. Education Access and Quality (graduating from high school, higher education, early childhood education and development)
  3. Social and Community Context (community cohesion, civic participation, discrimination, workplace conditions, incarceration)
  4. Economic Stability (poverty, employment, food security, housing stability)
  5. Neighborhood and Built Environment (quality of housing, access to transportation, availability of healthy foods, air/water quality, neighborhood crime, violence).

Addressing all areas of the framework requires multidisciplinary and multi-system collaboration. Both within the health care system and outside, there are a growing number of initiatives being implemented to promote health and health equity. With that in mind, iCare understands the value in partnering with our community providers to learn how SDoH impacts their practice and the existing resources available to their staff. Equally important, we want to ensure that our provider partners understand the services and programs we have available to our members.

Care Coordination Staff

Assisting our members with coordination of care begins upon enrollment. Each member is assigned to a Care Coordinator and Registered Nurse Case Manager. The Care Coordinator (CC) is an experienced professional who participates in assessments and care plan development to meet medical, behavioral health, functional, and social needs of members. They also monitor and evaluate members’ health and well-being, direct member’s care, educate members in self-management techniques, coordinate services and evaluate the effectiveness of the care plan. The Registered Nurse Case Manager (RNCM) is an experienced nurse available to help assess and address the medical and behavioral needs of members with rising risk. The RNCMs work collaboratively with the member, the member’s formal and informal supports, including the member’s health care providers and other community-based case managers when present, to ameliorate risk and meet the member’s health goals. In addition, the RNCMs assist in care transitions to reduce the potential for readmission and gaps in care. Moreover, the RNCMs are a source of clinical support for the CCs.

Would your patient benefit from care coordination services? Please reach out to iCare’s Customer Service at 1-800-777-4376 and ask to speak to their assigned CC or RNCM.

Health Coach/Community Health Worker

The Health Coach/Community Health Worker (HC/CHW) provides high touch support and coordination to address the social determinants impacting the health of iCare members. These individuals are an integral member of the interdisciplinary care management team. The HC/CHW work closely with designated iCare members, Care Coordinators, RNCMs, health care providers and community partners to effectively coordinate, support, and coach members in the implementation of the member-centered care plan. They help to develop and maintain partnerships with community-based organizations and assist members to connect with needed services to address social determinant needs and barriers.

While our HC/CHWs can address any SDoH need, one of iCare’s key initiatives focuses on housing and we have staff, including our Housing Navigator, readily available to assist our members with homelessness and homelessness prevention.

Could your patient use the assistance of one of our HCs/CHWs? Please follow up with their assigned CC or RNCM by calling our Customer Service line at 1-800-777-4376.

Intervention Specialist

The Intervention Specialist is an experienced behavioral health professional who works within the care management model to meet identified mental health and substance use disorder (SUD) needs of iCare members. This includes participation in assessments either telephonically or in person, care plan development, monitoring and evaluating member’s health and well-being, educating members in self-management techniques, coordinating behavioral health services and evaluating the effectiveness of the care plan to modify the member’s behavior.

Have you identified an iCare member that could benefit from working with an Intervention Specialist? Please follow up with a member of our staff to discuss your concerns by calling iCare’s Customer Service at 1-800-777-4376.

Patient Activation

Poor health literacy is a significant contributor to decreased adherence to medication regimens, a lack of understanding of post-hospitalization discharge instructions leading to high readmission rates, and overall low self-confidence in managing one’s own chronic diseases. One way that we are attempting to evaluate health literacy amongst our members is conducting the Patient Activation Measure (PAM) survey. The PAM survey is a 10-question assessment that categorizes individuals into four levels of activation and can be used to predict ED utilization, hospital admissions and readmissions, medication adherence, and other behaviors related to self-management of chronic conditions. The scores range from Level 1: Disengaged and overwhelmed to Level 4: Maintaining behaviors and pushing further. Patient education can be tailored based on the member’s score with the most attention given to those designated Level 1.

Do you have concerns about your member’s level of activation? Please feel free to follow up with our staff to determine their PAM score by calling our Customer Service line at

Readmission Prevention

Readmissions can occur secondary to a variety of causes including SDoH. Readmission Prevention activity begins as soon as we are notified of a member’s hospital discharge. Our staff conducts telephonic outreach within 5 days of an inpatient hospital stay to ensure that the discharge was appropriate, that members have scheduled follow up appointments, and that members understand their discharge instructions including newly prescribed medication. For our Medicare members ages 65+, we offer a special 30-day Readmission Prevention Program that includes frequent contact and a home visit from a Nurse Practitioner for those residing in Milwaukee, Kenosha, Racine, Waukesha, and Ozaukee counties. For members under 65, we have relationships with home health agencies in counties across the state to conduct a 90-day readmission prevention program.

Are you concerned that SDoH are the reason for your patient’s readmissions? Please follow up with a member of our staff to discuss your concerns by calling our Customer Service line at

High-Risk Disease Management

As members continue to struggle with SDoH, management of their diagnoses can become increasingly difficult. iCare has specialized teams for our Medicare and Medicaid members whose risk stratification assessment has identified them as high-risk. These teams have decreased caseloads and, if appropriate, will conduct home visits throughout the member’s enrollment in the program. Referral criteria can include: increased inpatient/ED utilization, active SUD, untreated mental health diagnoses, recent suicidal/homicidal ideation without evidence of established providers, and pregnancy with active SUD or untreated mental health diagnoses.

Do you have a member with SDoH concerns that would benefit from high-risk disease management? Please reach out to the assigned CC or RNCM by calling our Customer Service line at

Additional Benefits and Community Partnerships

In addition to the specially trained staff and programs available to our members, we’ve also developed relationships with organizations addressing health disparities in the communities we serve. As previously mentioned, homelessness and homelessness prevention are a top priority at iCare. We’ve streamlined a referral process with Guest House of Milwaukee that ensures our members have the best chance of success at obtaining and maintaining stable housing. We’ve partnered with Social Development Commission and their Senior Companion program to assist our members dealing with social isolation. Lastly, we have enhanced our benefit package to include coverage of certain over-the-counter items and gym memberships to name a few.

While significant progress has been made to recognize and address social determinants of health, challenges remain. How is your organization addressing SDoH? What partnerships have you developed in your community to assist your patients struggling with SDoH concerns? Are there any entities you’d like to see iCare partner with? Supporting each other as we assist our mutual patients/members struggling with SDoH is one way we can serve our community well.


References: About Social Determinants of Health (SDOH). (2020, August 19). Retrieved January 28, 2021, from


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