Impact of Social Determinants of Health on Utilization of TCM and CCM Services - Differences by Disability Status

Sep 28, 2026

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Transitional Care Management (TCM) and Chronic Care Management (CCM) services improve post-hospital and chronic-condition care, yet utilization differs across populations. Using 2016–2020 Medicare Current Beneficiary Survey data linked to fee-for-service claims, matched case-control studies (1:2) compared SDOH patterns for TCM-eligible and CCM-eligible beneficiaries, stratified by disability status. Findings show SDOH relates differently to TCM versus CCM, with environmental and access barriers lowering TCM use and economic instability and transportation barriers increasing CCM use, and disability status modifying these associations.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages1

Reading Time3 min

AccessFree to download

Background

Methods

Results

Differences by Disability Status

Implications for Care Planning

1308 Innovation in Aging, 2025, Vol. 9, No. S2 derived from 26 survey items, were standardized and analyzed via conditional logistic regression, adjusting for demographics and comorbidities. ForTCM, lack of healthcare access (adjusted OR [95% CI]: 0.85 [0.76-0.95]) and poor neighborhood environment (0 .83 [0 .75-0.93]) were associated with lower TCM utilization. The associations were stronger among those without disability than those with disability for healthcare access (0.80 [0.64-0.99] vs. 0.86 [0.74-0.99]), but stronger among those with disability than those without for neighborhood environment (0.81 [0.70-0.93] vs. 0.89 [0.74-1.07]) . For CCM, economic instability (1.16 [1.01-1.34]) and lack of transportation (1.21 [1.05-1.40]) were associated with greater utilization of CCM. However, stratified by disability status, these associations were attenuated and not statistical significant. SDOH impacts TCM and CCM utilization differently, with distinct patterns by disability. TCM under-serves those facing environmental and access barriers, especially individuals with disabilities, while CCM reaches people who are socioeconomically disadvantaged and less affected by disability. Integrating SDOH screening into care planning and aligning TCM and CCM delivery may improve equitable care. Abstract citation ID: igaf122.4357 IMPACT OF SOCIAL DETERMINANTS OF HEALTH ON UTILIZATION OF TCM AND CCM SERVICES: DIFFERENCES BY DISABILITY STATUS Eunji G. Kim1, Ellen McCarthy2, Dae Hyun Kim2, Lan Luo1, and Chan Mi Park3, 1. Marcus Institute for Aging Research, Boston, Massachusetts, United States, 2. Hebrew SeniorLife, Boston, Massachusetts, United States, 3. Hebrew SeniorLife, Harvard Medical school, Boston, Massachusetts, United States Transitional Care Management (TCM) and Chronic Care Management (CCM) services aim to improve post-hospital and chronic condition care, but utilization varies across populations. Social determinants of health (SDOH) can contribute to disparities in access to these services, especially among beneficiaries with disabilities. We examined how SDOH factors relate to TCM and CCM utilization, stratified by beneficiaries’ disability status. Using 2016-2020 Medicare Current Beneficiary Survey data linked to fee-for-service claims, we conducted matched case-control studies (1:2 ratio) of TCM-eligible (n = 4,762) and CCM-eligible (n = 25,380) beneficiaries. Eight SDOH domains,

FAQs

What services are studied in this work?

The study examines Transitional Care Management (TCM) and Chronic Care Management (CCM) services and how often they are utilized after hospitalization and for chronic conditions.

How were the researchers able to analyze utilization across populations?

They used 2016–2020 Medicare Current Beneficiary Survey data linked to fee-for-service claims and conducted matched case-control studies with stratification by disability status.

Do social determinants of health affect TCM and CCM utilization in the same way?

No. The results indicate different patterns: barriers related to access and neighborhood environment are associated with lower TCM utilization, while economic instability and lack of transportation are associated with greater CCM utilization.

How might these findings be used in healthcare planning?

The document concludes that integrating SDOH screening into care planning and aligning TCM and CCM delivery could improve equitable care.

Sep 28, 2026

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