Kristy Duffey, APRN, chief nursing officer for Optum Health and chief operating officer for Optum Home & Community Care, talked to the publication about how home-based visits have addressed gaps in patients’ social needs. Last year, Optum completed more than 395,000 house call visits in rural communities. The house-calls team screened more than 2 million members for social determinants of health needs, according to Ms. Duffey. From that, they made more than 408,000 referrals related to social determinants of health.
“If you break that down, 183,000 [referrals] 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,” she said.
In one example, a practitioner found that a heart failure patient who had been to the emergency department multiple times for congestive heart failure exacerbation was eating cans of high-sodium soup everyday.
“Something like that you can’t see in a provider’s office, but we are able to experience that [in the patient’s] home. We were able to teach her how to read the ingredients on the back regarding the sodium content intake,” and were also able to connect the patient with a dietician, Ms. Duffey explained.
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