Combating loneliness among seniors: The community-based palliative care approach to social determinants of health

Insight Article - March 24, 2020

Patient Engagement

Population Health

Greer Myers
Real-world experiences provide some of the most compelling examples of the impact of social determinants of health (SDoH) on individual health.

Take for example Claire, an 84-year-old woman with advanced diabetes who lived at home, was non-adherent with her insulin and frequently visited her local emergency department. As it turned out, she was unable to store her insulin properly because of a broken refrigerator.

Consider Betty: a 74-year-old woman with lung cancer who lived alone and had no children or family to help her. Her severe mobility issues prevented her from leaving the second floor of her home. While the daughter of her physical therapy aide came twice a week to leave her cooked vegetables, the lack of proper nutrition was beginning to impact Betty’s health, which led to numerous preventable and unnecessary ED visits.

It’s these types of non-clinical issues that confound not only patients with serious or advanced illness living at home, but also their physicians. When patients are grappling with complex clinical and non-clinical issues — such as SDoH or challenges associated with day-to-day living at home — they require more intensive services from their medical and social support teams to maintain health and functioning. The goal is to extend the reach of the medical practice into the patient’s home to resolve the issues before they become problematic and lead to complex health concerns that require hospitalization or costly intervention.

Increased recognition of SDoH and reimbursement  

A McKinsey & Company report found that non-medical factors — including the conditions in which people are born, grow, live, work and age — can have an enormous impact on health. From economic stability and education to access to healthy foods and reliable transportation, these social factors can influence an individual’s ability to effectively manage their health and get the right care when they need it.

In fact, recent studies show that social determinants matter more to health outcomes than medical services: SDoH drives more than 80% of health outcomes; 68% of patients face at least one barrier related to social determinants; and of these, 57% have a moderate-to-high risk for financial insecurity, isolation, housing insecurity, transportation, food insecurity and/or health literacy.

To help address these types of challenges, CMS now recognizes and reimburses for home-based palliative care in supplemental benefits related to SDoH. These include issues related to disease exacerbation, unmanaged symptoms, access to care, health literacy, food scarcity, home/neighborhood safety, social supports and family/caregiver issues.

By the numbers

To understand the effects of social determinants of health (SDoH), consider data related to social isolation, loneliness and hunger:
  • One study found that mortality increased by 26% to 32% for people who are socially isolated.
  • Loneliness is a unique predictor of higher blood pressure  and heart disease.
  • A 2015 meta review of 70 studies showed that loneliness increases a person's risk of dying by 26%.
  • Medicare spends about $134 more per month for each socially isolated senior than it does for other members — similar to costs associated with high blood pressure and arthritis.
  • Annual care for seniors who don’t have strong social connections is associated with an estimated $6.7 billion in additional Medicare spending.
  • Access to healthy foods is also central to good health and healing, but 35% of respondents in one study experienced food insecurity and were twice as likely to have multiple emergency room visits over a 12-month period.

The role of community-based palliative care: Improving quality and care coordination

Specialized community-based palliative care (CBPC) has been shown to relieve the additional burdens on already overworked medical practices and healthcare professionals who seek to address SDoH or other non-clinical issues. Innovative CBPC solutions are making a substantial difference in providing quality care and closing gaps in care for seriously ill patients living at home. Using predictive analytics to identify patients earlier in the disease trajectory provides a more sophisticated approach, predicting who is likely to experience an over-medicalized or inappropriate death.

This approach integrates structure and process into programs, services and in-home assessments and deploys dedicated clinician teams — including specially trained nurses and social workers — to engage with patients and caregivers in the home setting. CBPC nurses and professionals are specially trained to spend time in the patient’s home and identify unaddressed clinical issues, physical symptoms and determine basic social needs that might prevent the patient from addressing important goals of care and advance care planning.

For physicians and medical practices, this offers an opportunity to connect with patients upstream, help them cope better with an illness and mitigate its impact on their quality of life via whole-person care. It’s a way to address the simple needs of life first and provide access to resources, because a patient who is going hungry, for example, will be less inclined to focus on obtaining and taking medications.

Evidence-based care in the home

Typically, patients who require palliative care are identified through claims data that reflect clinical information, hospital visits, diagnoses codes, doctor visits and so on. This information is critical but fails to reflect a patient’s home environment. With a specialized CBPC program, patients are stratified, and the clinically more complex cases receive a visit from a specially trained CBPC nurse case and/or social worker who consults with the primary nurse to determine the types and intensity of their needs.  

For example, a patient who lives alone and has no caregiver or transportation will require more attention from the social worker, while a patient who requires attention for an infected wound may only require attention from a nurse. In this way CBPC relieves suffering and improves quality of life.
By providing needed insights and visibility into how the patient and caregiver are managing at home, specialized CBPC teams can quickly resolve issues — such as arranging to replace a broken refrigerator by coordinating with the patient’s caregiver and religious leaders; finding a neighbor who can drive a patient to a community day care to relieve loneliness; or arranging to have prescriptions delivered to the home for patients who don’t have transportation. Such quick and efficient resolutions result in a better health outcome and significantly reduce costs related to caring for these patients.

Structured CBPC extends the medical practice

The CBPC approach serves to extend the reach of a medical practice or hospital team into the patient’s home. When dedicated community teams of nurses and social workers make structured palliative assessments and interventions, they are able to evaluate and manage gaps in care, support care coordination and address SDoH. Such a process-driven approach goes beyond the traditional referral model and uses predictive analytics to identify patients earlier in the disease trajectory. 

A peer-reviewed study published in the April 2019 issue of the Journal of Palliative Medicine demonstrated the positive outcomes of a systemized, structured and evidence-based care management program that resulted in more compassionate, affordable and sustainable high-quality care, reduced utilization and lowered medical costs.

The primary goals are to promote effective patient, caregiver and medical team engagement; align care and support patients’ and caregivers’ goals, preferences, values and health status; and improve patients’ quality of life and the use of resources throughout their illness and at the end of life.

In the case of Claire, the 84-year-old woman with advanced diabetes who was non-compliant, the CBPC care team quickly identified that her refrigerator was broken and worked with the patient’s caregiver and religious leaders to get her one that worked. The result: a better health outcome and reduced cost of care.

For Betty, the CBPC care team assessed the situation and put “Cuisine for Healing” into place so that organic, locally prepared meals were delivered daily to her home. Doing so improved Betty’s nutritional status and reduced her social isolation.

Helping physicians deliver better care 

As physicians focus on an array of concerns that go well beyond basic patient care, they are also navigating an evolving Medicare landscape and value-based payment models that emphasize quality versus quantity. In an environment that often reflects a fragmented approach to care, physicians find it increasingly important to carefully organize personnel and other resources needed to carry out all required patient care activities.

A structured CBPC approach for care coordination allows physicians to better focus on providing high-quality medical care. It also helps them to achieve the Triple Aim of improving the patient experience of care (including quality and satisfaction) and population health, and reducing the per capita cost of healthcare. With this approach, all participants are better able to leverage community resources and remain informed about any challenges or care interventions that occur between regular patient visits.

Around the country, a growing number of physicians, medical practices and hospitals are partnering with CBPC solution providers. They are rising to the challenge, improving the health of people and populations they serve by helping to address some of life’s most basic needs — housing, clothing, food, isolation and transportation — and with some impressive results. A more holistic approach to patient care, exemplified by a CBPC solution, results in improved cost and quality metrics and welcome relief from the mounting pressures now confronting our nation’s physicians.

About the Author

Greer Myers
Greer Myers
President Turn-Key Health

Greer Myers can be reached at


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