Addressing Chronic Conditions and Social Support Needs: A Strategic Focus for Health and Human Services

Erica Stokes | June 20, 2024

A consistent theme this year in the health and human service field— and at Community Service Board of Middle Georgia (CSBMG)—is the focus on consumers with co-occurring behavioral health needs coupled with chronic conditions and social support needs. This focus is driven by compelling health care cost data, which reveals that a mere 10% of consumers are responsible for 70% of health system resources (National Institute of Health, 2023). Not surprisingly, behavioral health providers and payers are deeply invested in improving health outcomes and reducing costs for this population.

Chronic conditions, such as diabetes, hypertension, and mental health disorders, often require long-term management and substantial health care resources. When these conditions are coupled with unmet social support needs—like housing instability, lack of access to nutritious food, and limited educational opportunities—the challenge of managing them effectively becomes even more complex. Addressing these social determinants of health (SDOH) is crucial for improving health outcomes and reducing health care costs.

The social determinants of health encompass a wide range of factors that influence an individual’s health and well-being. These include economic stability, education, social and community context, health and health care access, and neighborhood and built environment (Office of Disease Prevention and Health Promotion, 2023). CSBMG recognizes that addressing these social determinants is essential for fostering holistic health and well-being in our community.

Our programs are designed to provide comprehensive support that addresses both the medical and social needs of our consumers. For instance, the Rise Up program not only offers medical assistance referrals if needed and addiction recovery support but also provides community outreach initiatives to enhance social support networks (CSBMG, 2024) which creates a more robust support system for individuals with chronic conditions.

Rise Up has successfully distributed Narcan kits and fentanyl test strips, preventing countless potential overdoses and saving lives in our community (CSBMG, 2024). Additionally, our parenting classes and donations to local jails help support vulnerable populations, promoting stability, food security, and well-being beyond immediate medical needs.

Our focus on addressing chronic conditions and social support needs aligns with broader trends in the health care field. Health systems and payers are increasingly adopting value-based care models, which incentivize providers to deliver high-quality care while controlling costs. By targeting the social determinants of health, we can achieve better health outcomes and create a more sustainable health care system (World Health Organization, 2023). The path toward CCBHC certification will enable CSBMG to better focus on integrated healthcare, essentially enabling our team to better treat the “whole” person.

In conclusion, addressing the needs of consumers with chronic conditions and social support needs is not only a priority for CSBMG, but the health and human services field at large. By focusing on social determinants of health and integrating comprehensive support services, we can improve health outcomes, reduce health care costs, and create a healthier, more resilient community. As we continue to innovate and expand our programs, we remain committed to serving the diverse needs of our community and promoting holistic well-being for all.

Community Service Board of Middle Georgia. (2024). Program highlights. Retrieved from
National Institute of Health. (2023). Health care cost and utilization report. Retrieved from
Office of Disease Prevention and Health Promotion. (2023). Social determinants of health. Retrieved from
World Health Organization. (2023). Value-based health care. Retrieved from