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The 3 Cs of home care: How home visits complement, connect and coordinate to improve mental health and other SDOH outcomes for seniors

How home visits complement, connect and coordinate to improve mental health and other SDOH outcomes for seniors

As health insurance programs increasingly move away from traditional-fee-for-service models to more holistic plans, a growing focus of whole-patient care for seniors is identifying social barriers that keep them from seeking preventive health care.

The pandemic has only underscored the importance of recognizing these challenges, known as social determinants of health, or SDOH, particularly when it comes to mental health.

One recent survey conducted by CVS and Morning Consult shows that 4 in 10 respondents ages 65 and older said they experienced mental health concerns for themselves, family or friends – a 10-percentage point increase compared with 2 years ago.i

Last year, the World Health Organization reported a quarter of Americans 65 and older were considered socially isolated,ii which the Centers for Disease Control says increases a person’s risk of premature death from all causes and increases the risk of dementia by 50%.iii Loneliness is also associated with higher risks of depression, anxiety, and suicide, according to the CDC.

The good news: an increasing number of Americans said the pandemic made them more comfortable reaching out for mental health support, according to the CVS/Morning Consult survey.iv And in-home assessment programs like Optum® HouseCalls are well-positioned to ensure that mental health is part of whole-patient care.

Defragmenting proactive care with the 3Cs

Using the three Cs – complement, connect and coordinate – HouseCalls is working to defragment care and ensure that mental health issues and other barriers to care are being addressed.

First, Optum advanced practice clinicians (APCs) complement a member’s existing care, carefully reviewing their records and working closely with the member’s primary care provider.

Second, Optum APCs connect directly with the member, spending up to an hour in their home doing comprehensive, multi-dimensional health evaluations and screenings that focus on both the physical and SDOH.

“When you see a member in their home, the social determinants of health experienced by a member become recognizable,” said Catherine Caspary, vice president of clinical operations for the Optum HouseCalls program. “You can identify the struggles that these members experience that prohibit them from meeting their health care needs. It’s an impactful component of our in-home program … seeing how they live. And then asking individualized questions during our time with them based on what we are observing.”

Finally, the APCs coordinate with the member’s PCP to help develop a member care plan, which Caspary said can include connections to social workers, care managers and local mental health and other community resources to “give them the timely help that they may need.”

It is not just one and done. It’s about what are the next steps.

Placing mental health at the center of home care

Social isolation, depression and anxiety among seniors have long been common struggles for many seniors but received more attention during the pandemic. That’s why they have always been a key element of consideration with HouseCalls visits.

“We ask detailed questions about how they’re feeling,” Caspary said. “If they answer positive to questions on the depression scale, we go into more detailed questions to understand how best to serve the member. Do they need immediate assistance? Do they need a referral? Based on responses, HouseCalls links members with behavioral services if needed and if the member is agreeable.”

As appropriate, all of that information is shared with the payer plan and, with the member’s consent, with their PCP so that they will know immediately whether there is an urgent need and what services and resources are available, said Adam Haddad, a business leader for the HouseCalls program.

And if the APCs live in the communities they serve, they can refer members to a variety of additional local resources, from food banks, financial aid or mental health services.

“I tend to think of HouseCalls as the foundation. We go in, identify the needs following the three Cs,” Caspary said.

“We complement the member’s regular care by identifying the member’s needs. We work with their doctors to help develop the best treatment plan. And finally, we connect them with the benefits their health plan offers and coordinate additional local resources we can find for them.”

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With an expansive network that can reach members, even in isolated areas, in all 50 states, Optum HouseCalls conducted more than 2.1 million visits in 2021, with 99%-member satisfaction. This thorough, 1:1 care that can identify critical SDOH factors provided payers with an in-depth understanding of member needs that resulted in an 86% Star gap closure rate.

For more information on the HouseCalls program visit www.optum.com/housecalls, or read the full version of this article.

The editorial staff had no role in this post's creation.