Connecting Provider to home: A home‐based social intervention program for older adults

Abstract

Objective Patients with multiple medical conditions and complex social issues are at risk for high utilization and poor outcomes. The Connecting Provider to Home program deployed teams of a social worker and a community health worker (CHW) to support patients with social issues and access to primary care. Our objectives were to examine the impact of the program on utilization and satisfaction with care among older adults with complex social and medical issues. Design Retrospective quasi‐experimental observational study with matched comparator group. Setting Community‐based program in Southern California. Participants Four hundred twenty community dwelling adults. Intervention Community‐based healthcare program delivered by a social worker and CHW team for older adults with complex medical and social needs. Measurements Acute hospitalization and emergency department (ED) visits in the 12 months preceding and following enrollment in the pilot program. A “difference‐in‐difference” analysis using a matched comparator group was conducted. Comparator group data of patients receiving usual care were obtained. Surveys were conducted to assess patient satisfaction and experiences with the program. Results The mean age of patients was 74 years, and the program demonstrated statistically significant reductions in acute hospitalizations and ED use compared with 700 comparator patients. Pre/post‐acute hospitalizations and ED visits were reduced in the intervention group. The average per patient per year reduction in acute hospitalizations was −0.66, whereas the average per patient reduction in ED use was −0.57. Patients enrolled in the program reported high levels of satisfaction and rated the program favorably. Conclusions A care model with a social worker and CHW can be linked to primary care to address patient social needs and potentially reduce utilization of healthcare services and enhance patient experiences with care.

Racial Health Equity and Social Needs Interventions

“…Among 152 studies in multiracial or multiethnic populations, only 21 (14%) 26 , 28 , 29 , 47 , 62 , 68 , 78 , 80 , 87 , 93 , 95 , 96 , 101 , 126 , 128 , 151 , 159 , 161 , 165 , 170 , 171 reported whether intervention outcomes differed by race or ethnicity of participants. Another 23 studies 23 , 30 , 34 , 35 , 58 , 63 , 66 , 74 , 82 , 83 , 85 , 92 , 94 , 102 , 117 , 129 , 135 , 142 , 143 , 163 , 167 , 168 , 169 (15%) included race or ethnicity in their analyses as confounders. The rest (108 [71%]) did not include race or ethnicity in their analyses at all.…”

“…When we considered the combination of conceptual thoughtfulness and analytical informativeness among studies that included race or ethnicity variables in their analyses, half of the studies (22 [50%]) were considered neither conceptually thoughtful for understanding root causes of racial health inequities nor analytically informative for advancing racial health equity research ( Table 3 ). 23 , 30 , 34 , 35 , 58 , 63 , 66 , 74 , 82 , 83 , 85 , 92 , 94 , 102 , 117 , 129 , 135 , 143 , 163 , 167 , 168 , 169 More than one-third (18 [41%]) were characterized as analytically informative but not conceptually thoughtful. 26 , 29 , 47 , 62 , 68 , 78 , 80 , 87 , 93 , 95 , 96 , 101 , 126 , 128 , 151 , 159 , 170 , 171 Among the 21 analytically informative studies, only 3 were also categorized as conceptually thoughtful.…”

Home-based primary care visits by nurse practitioners

“…Health care utilization outcomes were used as the main outcomes in all but two studies ( n = 12) (Bryant & Gaspar, 2014; Coppa et al, 2018; Counsell et al, 2007; Dick & Frazier, 2006; Jones, DeCherrie, et al, 2017; Kobb et al, 2003; Muramatsu et al, 2004; Palfrey et al, 2004; Stuck et al, 1995; Swartz & Meadows-Oliver, 2019; Wajnberg et al, 2010; Zimmer et al, 1985). The most common measure was hospitalization ( n = 12) (Bryant & Gaspar, 2014; Coppa et al, 2018; Counsell et al, 2007; Dick & Frazier, 2006; Jones, DeCherrie, et al, 2017; Kobb et al, 2003; Muramatsu et al, 2004; Palfrey et al, 2004; Stuck et al, 1995; Swartz & Meadows-Oliver, 2019; Wajnberg et al, 2010; Zimmer et al, 1985), ED visit ( n = 8) (Coppa et al, 2018; Counsell et al, 2007; Dick & Frazier, 2006; Kobb et al, 2003; Muramatsu et al, 2004; Palfrey et al, 2004; Swartz & Meadows-Oliver, 2019; Zimmer et al, 1985), and nursing home admission ( n = 3) (Stuck et al, 1995; Wajnberg et al, 2010; Zimmer et al, 1985).…”

“…Patients from disadvantage and minority groups often have unmet social needs that should be prioritized in interventions alongside their health needs (Kreuter et al, 2021). Community-based interventions have shown that addressing social needs can reduce avoidable health utilization and improve patient satisfaction Moreno et al, 2021). As many NP-led home-based interventions have been community based, they offer an innovative approach improving both social and health needs for marginalized populations.…”

Enhancing physician care of vulnerable older adults

“…Managing the care of vulnerable older adults can be quite challenging in a standard office practice, given the complexity of their care needs and the time limitations for each visit. In this issue of the Journal of the American Geriatrics Society , Moreno and colleagues present a retrospective quasi‐experimental observational study with a matched comparator group of a new model of care to assist in the management of frail older adults with complex needs within one of six SCAN provider partner medical groups in southern California serving an urban/semi‐rural ethnically diverse population 1 . A random sample of 420 patients, with average age 74, referred to the Connecting Provider to Home pilot program because their needs were felt to be too intense for usual care or because they had frequent hospitalizations or ED visits, were visited at home by a community health worker and a social worker for a comprehensive assessment.…”