Social Determinants Case Study
Cherokee

Detailed Patient Background

 

Cherokee is a 40 year old woman who recently acted as a live-in caregiver for her mother, who unexpectedly passed away. Her position as her mother's caregiver compounded the fact she couldn't work full-time, but to add to the burden of grief she has with her mother's passing, her social security income is discontinued which both mother and daughter were using as their main source of income. When living with her mother, due to the single source of income, they had a tight budget without the opportunity to establish savings. Now she has to move out of the apartment due to not being able to afford it. 

 

Cherokee has been doing her best to get connected to local resources but doesn't know where to turn. She has a high school diploma, but no means of personal transportation, which limits her job opportunities. Her ability to walk long distances is impacted by lower back and knee pain, which means she is restricted to an under 1 mile radius. She is living in a shelter in an urban neighborhood with high crime rates. All of this distress has made it difficult for Cherokee to cope and she is turning to alcohol as she lacks support structures. 

 

A social worker assigned to her case notices symptoms of depression and mania. They discuss her worries about getting a job as well as her mother's sudden death. The social worker notices Cherokee's self esteem is being afflicted with greater feelings of hopelessness and helplessness of believing things will never get better. The social worker themself additionally feels overwhelmed with the situation because of their high caseloads, limited time, and single-practitioner operation (lack of supporting health practitioners to assist Cherokee). He believes Cherokee will benefit from team-based care. 

 

Radect's Impact

 

This leads the social worker to contacting Radect Health for assistance. Once Cherokee is signed up, we provide her with a tablet and ensure she has an internet connection in her residence to be able to utilize the tablet. The first meeting is with the social worker and Cherokee to establish a baseline of her previous care. Next, her Radect team goes to work in designing her program. Our goal is to understand her circumstances and alleviate both the social/environmental determinants along with intrapersonal factors that are potential obstacles to Cherokee achieving her goals. We relate all the influencers so that her plan addresses the multiple aspects of her circumstances. Improvements in one area could lead to improvements in others if managed correctly; both short-term and long-term goals, along with strengths and assets she possesses are emphasized as a part of her program. 

 

Her Radect team sets up a preventative health plan based on her risk factors along with health literacy education so Cherokee understands the purposes behind her treatments. The yoga ambassador spends time with her remotely and collects vital health information to identify Cherokee's needs. Her physical therapist will review her lower back and knee pain and set up an appointment to discuss exercises that will improve her mobility. A dietician will review her current eating habits and establish a plan based on the foods available in shops in her area. In collaboration with the dietician, the yoga instructor will help her manage habits with meditation and positive-affirmations. We will evaluate her motivations and choices for exercise and activities. We will also address alternatives to make it easier for her to adhere to the plans. Her social worker will build an integrative therapeutic plan for her alcohol addiction and see if she would be comfortable attending virtual AA meetings that our team will help her get into. We will work with Cherokee to help her get connected with other support groups, such as a local grief support group that meets once a month. 

 

The social worker will oversee the main plan and review Cherokee's Radect health record regularly. They also continue to meet once per month with her and message the Radect team practitioners to provide additional levels of support and collaboration. This is combined with Radect's online studio activities as a part of her curriculum. Her yoga ambassador will be the lead for this, providing coaching for her activities and gearing them towards something she finds fun and will want to continue. They will also help her with stress management and mobility. Through coaching, our yoga instructors will work with Cherokee to develop a positive mental state and overcome her current mindset by reinforcing positive behaviors through a reward system. Cherokee will also receive worksheets to help improve her self esteem and reduce her limiting beliefs. 

 

Radect recognizes that Cherokee's health is impacted on multiple levels. The main focus of our team will be providing strategies and support that match her environment and the resources available to her (such as evaluating transportation options). We will partner with her to support her development outside of traditional health care (ex. a physical); which includes assisting her with computer literacy and educating her on her healthcare. We will help her get connected to outside sources that will help her obtain her life goals (such as someone who can help with financial planning and instruction to help her get a job). Throughout Cherokee's time with Radect, the yoga instructor reviews her social determinants of health and social and environmental situations to determine change and progress. This is discussed with the social worker and iterated over the year.