Partners in Primary Care Finds Success in Addressing Seniors’ Social Determinants of Health

There is growing recognition among healthcare providers and payers that disease prevalence is inextricably tied to social and environmental factors that impact health. In fact, clinical care accounts for an estimated 20% of health outcomes, while 80% are the result of social determinants of health (SDOH).

Millions of older Americans live in a precarious financial situation. Nearly one in four seniors has difficulty paying monthly living expenses, 24 percent are food insecure, many struggle with the cost of housing and homelessness is on the rise among this population. Many seniors lack access to transportation, preventing them from securing essential goods and necessary medical care and increasing their isolation.

These SDOH factors compound already high rates of mental health conditions among seniors, which, in turn, negatively impact their health.

Barriers to Addressing SDOH

Multiple obstacles, structural and attitudinal, make it difficult to address SDOH within the traditional care model. Physicians recognize the negative effects these factors have on health, but time and resources limit their ability to treat them. A study published in JAMA Network Open revealed that only 16% of physician practices screen for key social needs: food insecurity, housing instability, utility needs, transportation needs and interpersonal violence.

Lack of awareness of available social supports is one problem. Another is older patients’ hesitancy to share their non-medical struggles with clinicians. There is also little incentive or bandwidth for physicians to address these issues within the fee-for-service model. Traditional Medicare provides limited reimbursements for treating SDOH, making it infeasible for most practices to expand staff roles to address unmet social service needs.

Transforming Senior Care to Meet Medical and Socioeconomic Needs

Recent changes to Medicare Advantage Plans have enabled more holistic approaches to patient care by expanding the definition of supplemental benefits. The push toward value-based care has also significantly elevated the role of SDOH in treating patients, given their outsized impact on health outcomes.

These changes have created new models of senior care. One example is Partners in Primary Care, a network currently operating 56 senior-focused primary care centers – with 7 more that will open by the end of Q1 – throughout seven states. Partners accepts patients with any Medicare Advantage Plan and people eligible for both Medicare and Medicaid (dual eligible). These practices are made up of care teams that include a behavioral health specialist and a social worker who helps connect patients with needed services so mental health and SDOH issues can be addressed during visits.

Efficiencies gained across our centers allow our physicians to spend, on average, 45 minutes with each patient – triple the time most physicians can manage. Our value- based care model, focused on a whole- person health approach, encourages patients to be seen more frequently, not just when they’re sick. In the past three years, patients have had an average of five visits per year. That number of visits – plus the increased time per visit – enables stronger relationships to develop between the patient and our care team, creating a level of trust that allows patients to discuss their non-medical challenges and to accept assistance.

This holistic approach benefits both patients and payers. Data from our South Carolina centers showed that in 2019, 30-day hospital readmission rates for our patients were almost 60% lower than those of the general Medicare population. And, our rate of hospital admissions was 186 per 1,000, significantly lower than the national rate for this age group, which ranges from 233 per 1,000 (65 to 84 years old) to 456 per 1,000 (age 85+).

These value-based care-team models are reshaping patient care not just in treating their medical symptoms, but also in addressing the circumstances that often underlie those problems. Doing so can improve patients’ health and quality of life as well as reduce overall costs.

Author Renee’ Buckingham is president, Care Delivery for Humana. Humana’s Care Delivery Organization includes Partners in Primary Care – wholly owned, de Novo senior focused, payer agnostic primary care clinics; Family Physicians Group, a large senior focused primary care group located in Orlando, FL.