7 min read
By Marc Rothman, MD on 10/25/21 6:56 PM
Time has a special meaning in geriatrics, for both patients and the geriatricians like me that treat them. Older patients are focused on maintaining their function and independence so they can enjoy every day-week-month as happily and healthily as they can. Geriatricians know that to achieve those goals, we need time to connect with patients on both a personal and professional level. Doctors have traditionally been lucky to spend even 15 minutes with their patients — just enough time to cover the chief complaint and maybe some chronic disease basics.
But it’s not nearly enough time to comprehend and understand a person’s whole health. What is their functional status? What social support systems do they have in place (family, friends, others)? What worries them, and do they have the resources to manage their medical conditions and overall health? These things matter, and understanding them takes time.
Meeting patients where they are — in the home — offers an important opportunity to uncover and understand what is happening across multiple critical dimensions: clinical, functional, behavioral, and social. This is especially important for those living in rural areas and communities where access to care and services are limited. For the most vulnerable — the isolated, those who lack accessible transportation or have other obstacles that make it difficult to go to a doctor’s office — an In-Home Health Evaluation (IHE) by a qualified clinician can be an important tool for their primary care physician. They also help promote prevention, something that often gets lost in our current break-fix approach to healthcare.
For the 11 percent of those who receive an IHE from Signify Health who do not have a primary care physician, it may be the only time they actually spend with a clinician. For many of those, it’s the beginning of their re-engagement with their care team. Approximately 72 percent of the members who receive an IHE from Signify Health returned to an outpatient care setting post evaluation.
Activating the home as part of the care continuum
As Signify Health’s Chief Medical Officer, I oversee a nationwide network of more than 9,000 credentialed providers — physicians, nurse practitioners and physician assistants — who conduct annual, approximately one hour-long IHEs for members of Medicare Advantage insurance plans. Our clinicians play an important role in helping to activate the home as part of the care continuum. They evaluate health conditions and document social determinants of health that impact health outcomes, such as access to healthy food, transportation and financial resources for prescription drugs, home health services, and other needs. We also screen for worrisome issues that older adults often face, such as abuse, neglect, high fall risk, early dementia, polypharmacy, and others.
Often, Signify Health providers save lives. They frequently identify and intervene upon life-threatening situations that would otherwise have gone unnoticed, like a new heart rhythm, a blood clot, or a case of elder neglect or even abuse. For example, so far in 2021, we have documented 2,394 instances of exposure to violence which involved our contacting child and/or adult protective services. Our clinicians typically intervene in these and other such situations over 25,000 times a year — a small percentage of our total visits, but incredibly meaningful for those patients and their families.
Our practitioners can make impacts like these because our in-home evaluations are generally 2.5 times longer than a typical visit with a primary care physician (PCP) and include the following activities:
- A comprehensive health exam and medication review
- An assessment of current and prior health conditions
- HEDIS® care gap closure, e.g., HbA1c, microalbumin, colorectal cancer screening, diabetic retinal exam, bone density screening
- Screening for mental health conditions that have become more widespread during the pandemic, such as anxiety, depression and suicidality
- Identifying safety hazards in the home; for instance, fall risks, poor lighting, and unsafe bathing conditions
- Health education
Many people do not realize these in-home health evaluations are provided by Medicare Advantage plans to their members at no cost to the member. They are even more surprised to know that through the IHE, Signify Health clinicians capture up to 240 data points, well beyond what is typically captured during an annual Medicare in-office wellness visit. All of this information is shared directly with the member’s PCP and health plan in the form of care recommendations that can improve quality, wellness and outcomes for the members. The PCP, often along with a health plan case manager, is then able to follow up with the patient and work with them to ensure they get the care and services they need. In fact, 15 percent of those members we visit are referred to case management for multiple issues such as help with transportation, fall risk, home safety, and medication adherence.
Uncovering social determinants of health
IHEs can give primary care physicians another set of clinical eyes and ears to help confirm and complete a patient's records with observations that can only happen in the home. The in-home evaluation provides clinicians with an unparalleled view into members' social determinants of health and other issues that may not come up during a regular doctor’s office visit. Many of the health inequities that most impact a person’s health are literally hiding in plain sight, but impossible to observe directly in an office setting.
Our clinicians find out if the patient has enough healthy food to take with the medicines, if they are skipping doses or splitting tablets because they cannot afford refills, or if they are unable to get a refill because they do not have reliable transportation to get to the doctor or the pharmacy. These are the types of issues that we uncover at the kitchen table and that otherwise may go unaddressed. The pandemic only exacerbated these needs and in 2020, we connected more than 390,000 members with social care services in their community.
It was during a kitchen table conversation that one of our clinicians learned the member she was visiting only took his insulin once every four days because he could not afford to take it daily. She was able to connect him directly with a Signify Health social care coordinator, who helped him enroll in a prescription assistance program.
Situations like this are not uncommon. We find that in many cases, members have a social factor impacting their health and well-being that extends beyond affordability. For example, so far this year, 61 percent* of the members we have evaluated have a mental or behavioral health issue, 36 percent are experiencing food insecurity, 17 percent have a transportation need, and 30 percent are struggling with social isolation. For those living in rural communities, these issues are exacerbated by having fewer providers spread across larger distances and higher demand. Fortunately, we have access to community resources that can help these individuals get the care and support they need.
Ensuring data integrity
Having high-quality, comprehensive, accurate data is one of the most important tools in a physician’s medical bag. Signify Health is proud to have earned the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information (HEDIS) certification for several of our in-home screenings such as:
- Comprehensive diabetes care
- Diabetic eye exams
- Hemoglobin A1c (HbAfc) testing
- Diabetic kidney disease monitoring
- Blood pressure control
- Kidney health evaluation in patients with diabetes
- Colorectal cancer screening
- Osteoporosis management in women
More than 90 percent of the nation’s health plans look to NCQA as the leader to set the standard for high quality and customer service as indicated by the widely recognized NCQA seal of quality. The data we capture from these services is validated through a rigorous quality review process that includes multiple independent third party audits each year. But it is the people behind the data who matter most.
“You saved his life”
One of the most gratifying parts of our work is when we make a positive difference in the health and quality of life for the people we touch. Sometimes members will call or email after the IHE to let the clinician know what happened after the visit.
In a recent visit, one of our practitioners discovered circulatory issues in a man’s legs while conducting a physical exam. What she saw was so concerning that she advised him to go to the ER and helped facilitate getting him there. The hospital physician identified a blood clot and was able to start treatment immediately. The message from this member’s wife to the Signify Health provider was simple and truly powerful: “You saved his life.”
This story underscores why it is so important for the healthcare industry to keep moving towards a system that facilitates proactive prevention. The pandemic exposed the fragility of the Fee-for-Service infrastructure, the barriers to facilitating effective patient-physician relationships, and the impact those factors have on the quality of care. Evolving from this break-fix system to one that is based on value and shared accountability for improved outcomes means transforming both how care is delivered and how it is paid for. We need to do more to make preventative care happen holistically, year-round, by meeting members where they are and providing more preventive services in the home.
The Medicare Advantage program has been leading the transformation to value-based care through initiatives that facilitate person-centered care and align all members of the care team around a shared objective: to achieve the best health outcome at the lowest cost. The IHE plays an important role in the value continuum, offering an annual check point that supports both prevention and planning. It helps the health plans in their work to care for patients with complex needs. And, it helps bring care to rural areas and to those who have barriers keeping them from getting to care. It is time we do more to bring care to them.
It is extremely gratifying to see the impact that Signify Health makes each day, helping people gain more healthy, happy days at home. For the physicians, nurse practitioners and physician assistants who conduct IHEs, it’s what drives us, and it’s why we pursued a career in healthcare in the first place.
Marc Rothman, MD is the Chief Medical Officer of Signify Health and is triple board certified in Internal, Geriatric and Hospice & Palliative Medicine.
Learn more: Watch this short video to better understand the member’s experience during a Signify Health in-home health evaluation.
*Includes member-reported psychosocial stressors (e.g., due to COVID-19) and other conditions that may not rise to the level of a clinical diagnosis. Signify Health collects this information in order to develop a holistic picture of a patient's health and identify cases where non-clinical intervention may be appropriate to address social determinants of health