Integration of Care to Determine SDoH

June 23, 2022

Cost: $99
Date: Thursday, June 23, 2022; 1-2pm ET

Integration of Care to Determine Social Determinants of Health

Alliance Medical Ministry (AMM) has a patient population that faces an array of social risks (low income, uninsured, language barrier, low health literacy). An interdisciplinary care team of social work, counseling, nursing and primary care providers work in concert with patients to lower barriers to care. Nearly 60% of AMM's patients only speak Spanish and a large percentage have uncontrolled diabetes. Low health literacy and therapeutic inertia were targeted in this group by creating the Diabetes Care Management model, which allows a social worker and nurse to closely follow patients with uncontrolled diabetes. With frequent contact between the care manager, patient and primary care clinician, patients can gain better glycemic control in a shorter amount of time. The addition of donated continuous glucose monitoring devices provides even more information, to better assist patients with uncontrolled diabetes.

Target Audience

  • Consultants
  • Federal, state and employer wellness organizations
  • Health care decision makers
  • Health care professionals
  • Health plans
  • Health systems
  • Hospitals
  • MBHOs
  • Population health organizations

Learning Objectives

  • Highlight the benefits of interdisciplinary teams in managing chronic disease.
  • Discuss the contributions of the disciplines involved in each patient's care, including:
    • Behavioral health counseling.
    • Social work referrals to existing care in the area.
    • Partnering with community organizations.
    • Focusing time with the primary care clinician by having care teams follow up between visits.
  • Examine how to use patient interactions to engage patients in their health care.
  • Implement the Diabetes Care Management model in their own patient population.
Course summary
Available credit: 
  • 1.00 AMA PRA Category 1 Credit™
  • 1.00 ANCC
  • 1.00 IPCE
  • 1.00 Participation
  • 1.00 PCMH CCE
Course opens: 
Course expires: 
Event starts: 
06/23/2022 - 1:00pm EDT
Event ends: 
06/23/2022 - 2:00pm EDT

Nick Conde-Dudding, MSW

Social Worker
Alliance Medical Ministry

Mandy L. Horner, BSN, RN

Director, Nursing
Alliance Medical Ministry

Sheryl Joyner, MD

Internal Medicine Physician
Alliance Medical Ministry


In support of improving patient care, the National Committee for Quality Assurance is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), the American Nurses Credentialing Center (ANCC) to provide Interprofessional Continuing Education for the healthcare team. 

This activity was planned by and for the healthcare team, and learners will receive 1.0 Interprofessional Continuing Education (IPCE) credit for learning and change. 

This educational activity is approved for: 1.0 AMA PRA Category 1 CreditTM.

This educational activity is approved for 1.0 nursing contact hours.*

This live course grants 1.0 Continuing Education Unit (CEU) points for PCMH Certified Content Experts.  

* Please note – You must attend the entire program to be eligible for total number of contact hours.

Available Credit

  • 1.00 AMA PRA Category 1 Credit™
  • 1.00 ANCC
  • 1.00 IPCE
  • 1.00 Participation
  • 1.00 PCMH CCE


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