A Primer on Managed Care: Multiple Chronic Conditions

come of a disease. A life-course perspective con- siders social determinants of health factors as flexible pathways determining health outcomes over time. Consequently, social determinants can initiate the onset of pathology and thus serve as a direct cause for a host of chronic conditions (Cockerham, Hamby, and Oates, 2017; Holtz et al., 2008). The recognition that social determinants of health may be key to improving health outcomes and optimizing the use of healthcare resources has led to interest in creating strategies to man- age the relevant material need insecurities of individuals (Doran, Misa, and Shah, 2014; Egg- leston and Finkelstein, 2014; Garg, Jack, and Zuckerman, 2013). However, the knowledge base for this approach within healthcare systems remains limited. One study provides some evidence of a link between social determinants of health and healthcare utilization. Berkowitz and colleagues (2015) examined the association between social determinants of health factors and dia- betes control and healthcare utilization among 411 patients. Findings indicated that all mate-

rial need insecurities had some association with poor clinical control or increased utiliza- tion. For example, food insecurity was associ- ated with poor diabetes control and increased outpatient visits, while cost-related medica- tion underuse was associated with poor diabe- tes, cholesterol, and blood pressure control, and emergency department and inpatient care utili- zation. Moreover, housing instability and energy insecurity were both associated with increased outpatient utilization. Home- and Community-Based Services Home- and community-based services (HCBS) are designed to help community-dwelling older adults remain safely in their homes and com- munities and delay or prevent entering long- term-care facilities. Between 2002 and 2012, the number of Medicaid HCBS participants increased from 2.3 to 3.2 million (Ng et al. , 2015). The growing demand for HCBS stems in part from the increasing size of the older population, older adults’ desire to “age in place,” and increased federal pressure on states, most recently from the Affordable Care Act of 2010,

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