This blog was originally posted to https://allnurses.com/.
I still remember the first time I witnessed the impact of health inequities at work.
Early in my career, I considered myself understanding of diversity, equity, and inclusion, but I hadn’t yet directly seen the impact of health disparities. I was conducting in-home achievement testing for employers to assess employees’ cognitive abilities. One day, I visited a residence in a chaotic neighborhood with excessive loud noise, too many people without enough space, and children running in and out. Conditions were not conducive to administer the testing, but there were no other options for the employee. I was not surprised to see the employee’s scores were poor. Knowing their environment, I was obligated to share my concerns that the scores were affected by external factors.
I shared my broader concerns with my manager regarding the environmental and economic factors that were not only impacting the test scores but the overall care and success for this employee. I was told that those concerns were outside of the scope of services we were contracted to perform, and we had no basis on which to support my opinion. I was very concerned that the current care and support the employee was getting was not optimal, ultimately impacting the outcome of their case possibly impacting their ongoing benefits and return to work. I was compelled to tell the employer and explained that the results were not representative of true performance, advocating for another round of testing for the employee. The decision-makers reacted poorly, and my manager was not pleased, but when I stepped back to evaluate the situation, I stood by my actions. I didn’t have the resources to improve the employee’s care and conditions myself, but I knew the best I could do was to fairly and accurately convey the employee’s situation to the employer.
As board-certified case managers and disability management specialists, it’s our duty to ensure that everyone involved in a client’s care understands the social determinants of health (SDOH) affecting their return to work, to play, and to living. This requires us to be aware of equity, work to help them overcome barriers to access, and counter potential implicit bias. At CCMC’s 2022 Virtual Symposium  , I discussed this subject with a panel of CCMC Commissioners —certified case managers and disability management specialists — exploring the various nuances of equity in their work. The panel included R. Keith Franklin, PhD, LPC-S, LCDC, ACS, CEAP, CCM; Kendra Greene, MSN, MBA/HCM, RN, CCM; and Rebecca Fisco, CDMS.
How CCM and CDMS Certificants Demonstrate Fairness, Impartiality, and Justice in Daily Practice
Most of my career has been spent working with people different from myself. Cultivating awareness of those differences and my implicit biases enables me to better serve clients. It takes conscious effort to examine our daily experiences and how they differ from those of our clients, as affected by race, abilities, income, environment, and other such factors.
To accomplish this, we must understand the impact of SDOH, or common challenges impacting our communities such as lack of access to resources or care. We must frequently assess and understand our clients’ unique backgrounds to customize the services we provide and help bridge gaps.
Bridging these gaps requires us to constantly educate ourselves and others on issues factoring into equity. It’s our responsibility to communicate key information to stakeholders and connect clients with relevant resources. Disability management specialists representing employers can educate companies on gaps in their benefit offerings or income replacement offerings. We can ensure employees are aware of the level of care they should expect and have everything they need to understand their benefits. Case managers and disability management specialists can assess client needs and get them help from relevant community organizations to meet needs like transportation, nutrition, language translation, or financial assistance.
Identifying and Addressing Our Own Biases is Fundamental
We must evaluate how we’re perceived and how we perceive the world around us to ensure implicit bias doesn’t influence our interactions. I try to challenge my assumptions and check my gut reactions, gauging whether they are appropriate or exhibit bias. I also try to learn from my surroundings and be aware of how I am treated compared to others. For instance, when flying at a U.S. airport, if I raise an issue, it may be addressed differently than someone who speaks a different language. As another hypothetical example, a person of color who comes into an emergency care setting with a mental health crisis might behave similarly to a white patient but be treated differently from a white person, with staff being more likely to call security.
Assessing these situations and analyzing bias that can negatively impact outcomes is an important step to counter inequities. Implicit bias quizzes and training can illuminate types of biases to identify within ourselves. We should always assume positive intent from clients and support them regardless of our own beliefs or backgrounds. Acknowledging moments when we display bias facilitates growth.
Strategies to Improve Client and Provider Awareness of SDOH and Equity
Education and communication are fundamental to drive awareness. As a field case manager, it has often been my responsibility to help employers understand challenges pertaining to SDOH. If an employer didn’t feel that an employee was progressing from an injury or illness in the way they perceived the employee should, often they weren’t recognizing the factors that might be affecting those outcomes.
I’ve been fortunate to work for organizations with strong approaches to addressing health equity issues, from which we can glean valuable lessons, including in my work as a disability management specialist. These employers:
• Hold insurers and providers accountable for quality and accessibility of care;
• Empower employees through education and training to know what they should expect from care;
• Solicit feedback from employees to identify specific community challenges; and
• Take active steps to bridge gaps while continuing to solicit feedback on progress.
This approach can also apply to case managers, though the situation can be more delicate, as case managers often represent a provider or insurer. Generally, case managers should always:
• Understand how SDOH impact clients, which requires staying up to date on current research while asking questions and listening to clients;
• Maintain open lines of communication between stakeholders about SDOH affecting clients; • Identify quality of care, access, and resource challenges within communities served or those faced by clients;
• Empower clients in acute or recovery phases to navigate challenges by providing them with information and connecting them with resources; and
• Ensure the improved health outcome is sustained beyond the duration of the case management episode of care.
Case managers must set clients up for independent success managing their health. For example, once a case manager is no longer working with a client, it’s possible that the former client may experience a mental health crisis and require help from a counselor. The former client may be able to evaluate quality of care and identify potential workarounds if the right provider is not in network. If they need to travel out of network for the right provider, they may be able to successfully attain transportation and make the case for coverage to their insurer. We must strive to educate and empower clients so they can navigate the health care system without us.
Partnerships with community groups, public health organizations and local leaders can drive awareness of gaps in access, as *Kendra  noted in the Virtual Symposium session. Insurers often have social responsibility teams that arrange these partnerships, such as with local food banks. Case managers can assess how clients are affected by SDOH and share information back with key decisionmakers to inform initiatives addressing SDOH in their communities.
Identifying Equity Tools and Resources
Interpersonal connections can yield resources for our own learning and for our clients, as can actively seeking out tools through research; community engagement; networking; and serving on professional organizations, committees, and boards. There are many online resources that can be helpful, including through the CDC and Health and Human Services.
In my experience, employee resource groups are an excellent way to share tools and for employees to discuss how to bridge gaps. I am currently in one of these groups and employees post there to discuss challenges and exchange resources. This grassroots-level effort demonstrates how open dialogue can fuel change.
The Value of Education and Empowerment - Understanding Health Benefits
While education drives knowledge we have and share, we must also empower clients to understand their health plans and benefits and equip them to manage their care on their own. We must empower clients to embrace responsibility for understanding and using their own benefits, encouraging them to ask questions and seek help when they need it.
It's also fundamental to keep cultural competency in mind, listening and tailoring our approaches to fit our clients. At one of my former roles, we organized health fairs. One such fair was attended largely by a LatinX population. We communicated outcomes to participants to drive behavioral changes but we soon identified the participants were not the health care decision makers which drove us to ask questions. Through that exploration, we identified the decision makers and built into our process a release to share health information with the employee’s respective partner and decision maker and we began to see change and get positive feedback from participants. We wouldn’t have known without asking questions, listening to them, and responding accordingly — a lesson that should always be applied in client interactions.
Ongoing Learning and Skill Development
The Commission for Case Manager Certification offers many avenues for continuing education on health equity and social determinants of health, including this webinar on the latest health equity data from the Commonwealth Fund, or this issue brief on social determinants of health . I encourage you to explore them and share these tools. Building a culture of tolerance, understanding, and diversity requires a lifelong commitment to learning, and that makes case managers and disability management specialists valued resources in this fast-paced, evolving landscape.
 Fisco R., Greene K., Keith Franklin R., Quick E. Better You, Better Team, Better Outcomes: The “E” in Diversity, Equity & Inclusion. Digital presentation at the Commission for Case Manager Certification Virtual Symposium; October, 2022.
 * Kendra Greene, MSN, MBA/HCM, RN, CCM
Health equity: Access-to-care data helps us understand racial and ethnic disparities | Commission for Case Manager Certification (CCMC) CMLearning Network® Webinar. https://ccmcertification.org/archived-webinars/health-equity-access-car…
A call to action: Case managers can help build healthy, equitable communities. Commission for Case Manager Certification CMLearning Network® Issue Brief. Published December 2020. https://ccmcertification.org/sites/ccmc/files/issue_brief_pdfs/ccmc-dec…