Social determinants of health and utilization of transitional and chronic care management services among Medicare beneficiaries: a case-control study.

Background and Objectives The Centers for Medicare & Medicaid Services launched transitional care management (TCM) and chronic care management (CCM) services to improve care coordination. However, the social determinants of health (SDOH) that affect access to these services remain poorly understood....

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Published in:Gerontologist Vol. 66; no. 7; pp. 1 - 8
Main Authors: Park, Chan Mi, Kim, Eunji G, Luo, Lan, Shi, Sandra M, McCarthy, Ellen P, Kim, Dae Hyun
Format: Article
Published: Oxford University Press / USA Jul2026
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      dt: Jul2026
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      pub: Oxford University Press / USA
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        10.1093/geront/gnag113
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        atl: Social determinants of health and utilization of transitional and chronic care management services among Medicare beneficiaries: a case-control study.
      aug:
        au:
          Park, Chan Mi
          Kim, Eunji G
          Luo, Lan
          Shi, Sandra M
          McCarthy, Ellen P
          Kim, Dae Hyun
        affil:
          Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, United StatesDivision of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
          Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, United States
      su:
        Centers for Medicare & Medicaid Services (U.S.)
        Health services accessibility
        Social determinants of health
        Medicare
        Sex distribution
        Food security
        Economic status
        Communities
        Population geography
        Age distribution
        Transportation
        Chronic diseases
        Case-control method
        Rural conditions
        Metropolitan areas
        Social support
        Educational attainment
        Medical care costs
        Activities of daily living
        Medical care use
        Mathematical variables
        Research funding
        T-test (Statistics)
        Long-term health care
        Logistic regression analysis
        Socioeconomic disparities in health
        Shopping
        Continuum of care
        Functional status
        Chi-squared test
        Descriptive statistics
        Transitional care
        Odds ratio
        Longitudinal method
        Surveys
        Research
        Confidence intervals
        Treatment delay (Medicine)
        Medical care for older people
        Meals
        Data analysis software
        Neighborhood characteristics
      sug:
        subj:
          Health services accessibility
          Social determinants of health
          Medicare
          Sex distribution
          Food security
          Economic status
          Communities
          Population geography
          Age distribution
          Transportation
          Chronic diseases
          Case-control method
          Rural conditions
          Metropolitan areas
          Social support
          Educational attainment
          Medical care costs
          Activities of daily living
          Centers for Medicare & Medicaid Services (U.S.)
          Administration of Human Resource Programs (except Education, Public Health, and Veterans' Affairs Programs)
          Other support activities for transportation
          All Other Support Activities for Transportation
          Other Individual and Family Services
          Medical care use
          Mathematical variables
          Research funding
          T-test (Statistics)
          Long-term health care
          Logistic regression analysis
          Socioeconomic disparities in health
          Shopping
          Continuum of care
          Functional status
          Chi-squared test
          Descriptive statistics
          Transitional care
          Odds ratio
          Longitudinal method
          Surveys
          Research
          Confidence intervals
          Treatment delay (Medicine)
          Medical care for older people
          Meals
          Data analysis software
          Neighborhood characteristics
      keyword:
        Care coordination
        chronic care
        coordination of care
        copyrightHolder:The Gerontological Society of America
        copyrightYear:2026
        Health disparities
        Health services utilization
        https://dx.doi.org/10.1093/geront/gnag113
        inLanguage:en
        medicare
        Medicare beneficiaries
        publisher:Oxford University Press
        sameAs:https://pubmed.ncbi.nlm.nih.gov/42166741/
        social determinants of health
        transition of care
        transportation
        Care coordination
        chronic care
        coordination of care
        copyrightHolder:The Gerontological Society of America
        copyrightYear:2026
        Health disparities
        Health services utilization
        https://dx.doi.org/10.1093/geront/gnag113
        inLanguage:en
        medicare
        Medicare beneficiaries
        publisher:Oxford University Press
        sameAs:https://pubmed.ncbi.nlm.nih.gov/42166741/
        social determinants of health
        transition of care
        transportation
      ab: Background and Objectives The Centers for Medicare & Medicaid Services launched transitional care management (TCM) and chronic care management (CCM) services to improve care coordination. However, the social determinants of health (SDOH) that affect access to these services remain poorly understood. Research Design and Methods We included Medicare Current Beneficiary Survey participants from 2016 to 2020. 6 SDOH domains: Economic stability; Social support and community; Healthcare access; Transportation; Education; and Neighborhood environment were measured. We performed a conditional logistic regression to model receipt of TCM or CCM as a function of the 6 SDOH domains and covariates. Results 682 TCM cases were matched to 1,364 controls, and 362 CCM cases were matched to 724 controls. Compared to controls, TCM recipients were older (mean [ SD ] age, 76.3 [ SD 10.9] vs 70.9 [13.2] years), as were CCM recipients (74.4 [10.5] vs 73.2 [10.6] years). Greater social disadvantage was associated with lower odds of TCM receipt. Specifically, poorer healthcare access (tertile 2 vs 0: OR 0.61, 95% CI 0.42–0.88) and rural residence (OR 0.48, 95% CI 0.34–0.68) were associated with reduced TCM use. In contrast, greater economic instability (per 1− SD increase: OR 1.16, 95% CI 0.97–1.38) and transportation barriers (OR 1.16, 95% CI 0.99–1.36) were associated with higher odds of CCM use. Discussion and Implications SDOH has divergent associations with TCM and CCM utilization, revealing potential inequities in access to timely post-discharge care, with CCM may be reaching more socially vulnerable individuals.
      pubtype: Academic Journal
      doctype: Article
      src: R
    language: English
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