Resolving SDoH through Home-Based Palliative Care — One Patient at a Time

Published July 14, 2020

The pronounced impact of social determinants of health (SDoH) for seriously ill people during the COVID-19 pandemic is generating significant interest and response from payors, providers, and regulators in both private and public sectors.

These determinants include social isolation, loneliness, limited food access, financial or employment insecurities and lack of transportation. In fact, recent studies estimate that social determinants can be responsible for up to 80% of a health outcome.

These issues have prompted a growing number of payors to adopt home-based palliative care (HBPC) to address challenges for seriously ill members living at home. Interdisciplinary palliative care teams are well equipped to help resolve SDoH and have the skills to find resources, coordinate care and enhance communication among the plan member.

Take for example, Betty, a 74-year-old woman with lung cancer who lives alone and has no children or family to help her. Her severe mobility issues prevent her from leaving the second floor of her home. While the daughter of her physical therapy aide comes twice a week to leave her cooked vegetables, the lack of proper nutrition is beginning to affect Betty’s health status. This has led to numerous preventable and unnecessary ED visits.

Tackling SDoH with Palliative Care Teams

Taking an optimized, process-driven approach for resolving SDoH, Turn-Key Health’s Palliative Illness Management™ (PIM). PIM is an innovative, high-touch, home- based program designed to motivate patients and caregivers to be fully engaged in choosing and implementing a plan of care that optimizes their quality of life and results in treatment decisions in concordance with their goals, preferences and values.

PIM serves as a collaborative partner for health plan case managers, deploying a dedicated palliative care team – primarily nurses and social workers – to engage with members, like Betty, in the home environment and provide a first-hand look at specific situations and problems.

For Betty, the PIM care team assessed the situation and put a food delivery service 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. It also prevented costly clinical issues and gave Betty a more compassionate, affordable and sustainable level of care.

The Value of PIM to Address SDoH

The PIM program addresses SDoH, supports advance care planning, reduces over-medicalization and helps nurse coaches to establish a more robust relationship with members. What’s more, payors can scale these programs across broad and diverse geographic regions effectively implementing this level of engagement for their membership.

Read Turn-Key Health’s latest white paper, “Home-Based Palliative Care: Resolving Social Determinants of Health (SDoH) Issues — One Person at a Time.”