Impacting SDOH for patients and communities

Edward Prewitt:               Thank you. I'm here with Kristy Duffey, Chief Nursing Officer for Optum Health, the Chief Operating Officer for Optum Home and Community Care. Talk about what she and Optum have learned about how to address the social determinants of health over a decade of delivering in-home care for patients. Welcome, Kristy.

Kristy Duffey:                    Hi, Ed. Thank you. I'm really excited to be here today.

Edward Prewitt:               Thank you. So Kristy, given your role at Optum Home and Community Care, tell us how the healthcare industry approach to social determinants of health has been evolving over the last decade.

Kristy Duffey:                    Yeah, I have to say there is much more awareness of social determinants of health and social needs now. It's really the number one priority where it hasn't always been that way, Ed. In the past, the medical community had really been focused on medical care and not necessarily addressing a person holistically, more about patient volumes versus value. So having to see large amount of patients a day versus being able to spend that time with your patient. And traditionally what we have found is that healthcare has been more facility based, hospitals, physician offices, and free-standing labs or radiology centers, so more bricks and mortar.

                                             Our model is really about care at the home where we have the ability to address the patient's needs right in the comfort of their home, spending on average an hour with them if needed. We can assess if transportation is a barrier to care, and we can help arrange for transportation right at the time of that visit. If the patient doesn't have a primary care provider, we can find them one, and if there isn't one in their area, we actually can become their primary care provider. If they're having trouble paying for their food or medications, we can assist. These are just a couple examples of how in-home clinical assessments help us understand people's needs, and then we can coordinate appropriate follow-up care to ensure that there's resolution, which is really key. Making sure that when we're identifying these gaps in care, that we close the loop.

Edward Prewitt:               And now the federal government is bringing more attention to social determinants. Why is that, and what does it mean for your organization?

Kristy Duffey:                    Well, it's great. In December of 2022, the CDC actually identified social determinants of health gaps as a multifaceted public health problem. And the US Department of Health and Human Services released Healthy People 2030, a program that has identified social determinants of health as one of its top priorities. I'm really excited that social determinants of health now has national attention that honestly, it has needed for years.

                                             SDOH gaps impact populations, some of them more than others. And in fact, what we're seeing is our Medicare dual and chronic special needs populations, they have significant needs and require a far more individualized approach to care. On average, we see that they're managing nine different chronic conditions. Many of them are disabled, lack transportation, and they live in remote areas. I would say the homebound population is just another example. There are more than 2 million Medicare beneficiaries who are completely homebound, and there's another 5.5 million who need some level of assistance just to leave their homes.

                                             At Optum, we're continuing to grow our in-home care models to better address social determinants of health needs for these unique populations. And the research is showing that closing gaps in care with in-home assessments like our Optum HouseCalls program, it actually decreases hospital admissions by up to 14% and increases physician office visits by up to 6%.

Edward Prewitt:               So talk about Optum's approach to in-home care. How do you do it and how is it making a difference for social needs?

Kristy Duffey:                    Sure, I'd love to. In 2022, our HouseCalls program completed more than 395,000 visits in rural communities. Over 80,000 virtual visits were completed, and our Optum HouseCalls team actually screened over 2 million members for social determinants of health needs. We made more than 408,000 social determinants referrals. And if you break that down, those referrals, 183,000 were for people who needed financial support, 118,000 for people who needed transportation, 64,000 for food insecurity and another 43,000 for medication affordability.

                                             When we look across Optum home and community, what we find are four areas of need, the top needs. One, financial support, people needing help paying for utilities, their phone, clothing. The second is transportation, being able to get to their provider's office for appointments or go to the grocery store to get their food. Our number three top priority is assistance at home. So that's caregiver support, social isolation, supporting those in their home.

                                             And then the fourth is food access and food insecurity. I would like to just underscore that people's homes are really where health decisions are made on a daily basis. To have the ability to look in someone's refrigerator and see what food they have in their fridge or if they even have food, the ability to see if they can get up and move about, and then their social interactions with their friends and their family. Seeing people in their living environments, it really provides significant benefits.

                                             I just want to highlight a real life example of a patient that we saw in her home and she was new to us, our Optum home program, and had been back and forth to the emergency room, had been hospitalized several times for CHF exacerbation. And when we went into the home, the patient had said she didn't understand why. She's taking her medications regularly, she's not putting any salt on her food, doesn't understand why this continues to happen. And as the practitioner was in the home, she could see the food sitting on the counter, and the food that was on the counter was cans of soup, and that's what she was eating every day. Cans of soup, which have a thousand to 2000 milligrams of sodium, which was putting her into heart failure.

                                             Something like that you can't see in a provider's office, but we're able to experience that in her home. We were able to teach her how to read the ingredients on the back regarding the sodium content intake. But not only did we do that, we also had a dietician work with her to understand what foods she should be eating and not eating as well as helping with the shopping list so that we could help her with the foods that she needed to buy to help her not go into a CHF exacerbation. And so that is the biggest thing, as we identify those gaps in care, while we're in the home, ensuring that we're closing those gaps and helping our patients through the journey.

Edward Prewitt:               Well, that's a great real life example. Now, you've been doing a lot of work in this area for quite some time, as evidenced by the numbers that you mentioned, 395,000 visits in rural counties last year. What can people expect out of a next generation experience for in-home care?

Kristy Duffey:                    Well, when I think about that, I really believe care in the home is the solution to getting the right care at the right time to the people who need it most. Now, I'm not saying that office visits are going to go away, but I truly believe that home care is one leg to the stool and that healthcare is not one size fits all. So when we think about our in-home programs and our initial in-home visits with Optum, I believe that it opens the door to longitudinal support from an interdisciplinary care team supporting the patients through their transitions of care, as well as helping the patient navigate their care.

                                             And one thing I just want to point out when we think about nextgen is that Optum is now including social determinants of health as part of our risk stratification for our patients. Historically, payers and plans have not done that. Typically, they've pulled in medical diagnoses, medical claims information. It has been more reactive versus proactive. Before we weren't even capturing this data in the EMR. Now we're capturing social determinants of health in the EMR, assessing what are the patient's current needs, as well as we're anticipating those needs so that we can provide the right resources to help close those gaps.

                                             And we've also changed care teams to better suit our patients. For instance, we're bringing in dieticians, care navigators, community health workers, behavioral health advocates, pharmacists, nurses, NPs, PAs, and physicians to meet our patients' needs. Because when you think about it, health is fluid, so care and support, it needs to be dynamically adjusted based on a patient's risk. You have a stable patient, a rising patient, and a highest risk patient. All of those needs are different.

                                             A stable patient may receive an annual visit and support through digital tools or intermittent telephonic outreach, whereas a rising risk patient may receive additional visits with higher clinical touch. They may have on-site visits by a nurse or a social worker or a nurse practitioner. And the highest risk patients have much more frequent touch with the interdisciplinary care team that I just mentioned. They could get a visit every day, once a week, or once a month depending on their need.

                                             I would say the other thing that we're seeing, Ed, is that patients have really shown an increase of acceptance for digital tools and virtual care, especially in the past three years. Digital tools and platforms are crucial for people who face barriers like living in rural communities or lacking transportation to access care. We're also providing tablets for those that don't have access to smartphones. And I would say last but not least, our focus has to be on data interoperability. We have to be able to connect across systems. It's key for our provider experience as well as our patient experience so that they can have a seamless patient journey.

Edward Prewitt:               Well, that's really encouraging. I know that many organizations have found it very difficult though to address the totality of social needs, but what do you suggest to those feeling that way?

Kristy Duffey:                    Yeah, I would say when I think about this, collaboration is the key. It's the key to address social determinants of health. There isn't one employer, payer, or provider that can be an expert. We have to build relationships and coordinate with external parties as well as forge partnerships with networks in the community, local support service. I think we all know healthcare and health support, it's local. And we need to be thinking about a clinical model really rooted in value-based care and alignment of the payer as well as the provider.

Edward Prewitt:               So social determinants of health is about patients, but as a leader of clinicians, how do you find that it impacts your team addressing these issues?

Kristy Duffey:                    It impacts my team and really all clinical teams in a lot of ways. I've been reading some studies on this and some recent studies have demonstrated a direct or potential link between clinical burnout and the ability to address patient needs. I would say as a clinical leader, we have got to make it easier for our clinicians to serve our patients. We have to provide them with the right data, the right tools, the right technology. And when I say tools, it has to be actionable. They have to have tools that can close the gaps in care, but also we have to provide the resources to help them focus on the patient's needs. I can't say it enough. We have to have a team approach. This cannot all fall on the primary care provider. We have to have incentives in place and the right community partnerships to lean on.

                                             I also believe we got to have the space and time to build the trusted relationships with our patients. They trust us as providers. So that we not only uncover the social gaps, but also create a dynamic where patients are more likely to engage in the support that's offered by our teams. I do believe that if we do this, our providers will see that patients' social needs are alleviated, which actually in turn will help address our clinicians' own wellbeing and their morale, which will decrease burnout.

Edward Prewitt:               Thank you, Kristy, for a really informative discussion.

Kristy Duffey:                    Thank you, Ed. I really appreciate the opportunity to be with you today.

Edward Prewitt:               I would now like to introduce Dr. Tom Lee, Editor-in-Chief of NEJM Catalyst, who will lead the next segment of our program.