Speaker 1: We're able to assess their environment, what's in their cupboards? Do they have heat? Do they have air conditioning? Do they have electricity? Do they have running water? I mean, if basic needs aren't met, we obviously know that health needs are not gonna be met.
Speaker 2: Welcome back to Until It's Fixed, where we explore new ideas and work underway to make healthcare simpler and more effective for everyone. I'm your host, Callie Chamberlain.
Speaker 3: And I'm Dr. Kenny Pool.
Speaker 2: [00:00:30] Hi everybody. Welcome back. Today we're gonna be talking about home and community-based care. Where I began with this episode in reflecting on the topic is thinking about the question of where is home for you and what is home to you? And to me, home is not actually a physical location. It's people and it's relationships. So I really love this idea of community home care and how those things intersect specifically within this episode. So as we [00:01:00] know, lots of people would answer that question of what is home in a variety of different ways. Home-based care, community-based care really is thinking expansively about where home is for people and who home is for people, and making sure that through those different avenues people are able to receive the things that they need to be healthy. It might mean that there's a provider that is going to meet somebody not just in a single family home, but potentially in an assisted living facility or a homeless [00:01:30] shelter.
Speaker 2: And it's going to be personalized care because it's someone that's coming to the patient to meet with them, to sit with them, to listen to what their concerns are. And it's not just older people, people who are 65 plus and maybe have different levels of mobility. It's also people who are pregnant. It is also people who might have serious health conditions. And being able to think expansively about home and community really connects into this idea of community [00:02:00] and home-based care that we're gonna get into in this episode. The other thing to reflect on is that people's homes are such intimate spaces. It's where they're living, they're working. I mean, during Covid we started to think about our homes a little bit differently. And from a health perspective, it's also where these really important health decisions are being made. And it's where the conversations are happening, about what type of care we wanna receive, what's important to us, what type of provider we wanna interact with, what [00:02:30] type of food we have in the fridge.
Speaker 2: I think about the home as being able to facilitate those social interactions with family, with friends, which is also such an important part of communal health and wellbeing. From that perspective, it's even more interesting to me that we're starting to think about people's homes as a space where we can provide healthcare in a really interesting, different and meaningful way. For me as a birth doula and a end of life doula, that makes sense, right? A lot of my work [00:03:00] is going to meet people where they're at literally being inside their homes. And what I've noticed is that being able to be with them in that space facilitates such an intimate relationship because we're not just gonna go through a really intense experience together and know that that is something we're preparing for, but I'm also getting to see them in their space. And that helps deepen a connection in a way where I feel much more a part of that person's life and also better able [00:03:30] to support them because I understand the context in which they are coming from.
Speaker 2: I also had the experience of before my grandmother died, having her receive in-home care. And that person who was coming to the house became a part of my family's experience with my grandmother, and therefore she became a part of our family too. She came over every day, she would give my grandmother a bath, she would talk to my dad, they would coordinate care, they'd talk about medication. And [00:04:00] in so many ways, she was like our trusted resource because she knew what was happening with my grandmother. She had specific training, so she had insight we weren't able to observe, and she was with her in a way that was just not really possible for our schedules. And so I think about that also contributing to home and communal care where it's not just the place, it's like the deepening of a relationship that I think sometimes can be missing when, for example, I go see a doctor and [00:04:30] I feel like I'm just getting moved in and out, right?
Speaker 2: Like I wanna have a deeper conversation. I wanna feel connected to my provider. Sometimes I have to share more intimate details about my life. And it's hard when I'm like, okay, I have like 30 minutes with you. Right? And so the experience of being able to sit with somebody and like really be with them and be present with them, I think is what's missing in so much of traditional medical settings. And I really am excited about what could be possible [00:05:00] in home and communal care because if we can build that type of relationships with our patients, with our providers, I mean, think about how that ripples out with how we build relationships with other people, how we start to trust the industry different, how we start to think about our communities more expansively. I think it's really beautiful. And today we're gonna learn even more about the current state of home-based and community-based care to do that, Kenny and I spoke with Kim de Macy, she's a clinical team manager, nurse practitioner at Optum, as well as a nonprofit [00:05:30] founder and volunteer. She started a food pantry that has been running for almost 18 years and serves a thousand people a week. Let's listen in.
Speaker 4: We've been excited to learn more and wanna say thank you for being a part of this and giving us your time today. Well
Speaker 5: Thank you guys for the privilege.
Speaker 4: Well, so just to start, can you give a little bit of background about yourself and how your [00:06:00] career evolved into this type of work?
Speaker 5: Yeah, so I was an RN and I worked in I C U in a hospital for over 20 years. And I just was looking for something different and I started with hospice and palliative care in the home. It was really an exciting opportunity to see people in their own surroundings. When I found Optum House calls, I was like, somebody finally gets it. That preventative care is so much better than trying to [00:06:30] fight all of these diseases and you know, give pills to people on different things. So I think the prevention side of it was what really excited me.
Speaker 4: So Kim, can you kind of just set the stage for exactly what it is that you are doing? Like what does a day in the life look like for you?
Speaker 5: Yeah, so what we do as an annual yearly visit for the Medicare Advantage members, we go over their immunizations. We go over their screenings that they need for their age, give them education, help them to understand [00:07:00] why they're taking certain medications and the importance of taking 'em. We usually see about seven members a day. And so most people are working a 10 hour shift. We have schedulers that will set up our area that we're gonna work in, but we are driving probably a hundred to 150 miles a day to see that many people. Oh wow. You just learn so much when you're in their house. You see what kind of neighborhood they live in, what their safety is like if they have food in their house, if they have [00:07:30] electricity. I've gone into houses before that didn't have heat, so you just learn a lot more than you would learn if you were sitting in an office.
Speaker 2: Wow. Yeah, I, I'm sure that's really hard seeing people who are living in tough conditions. I'm also wondering what other challenges you might see.
Speaker 5: Well, there are days that you will go to houses that people are very depressed, they're not able to keep up with their housework, they're socially isolated. So I think [00:08:00] those are the hardest things.
Speaker 4: On the other end. What's been the most rewarding? And I'll ask you that both personally and also professionally.
Speaker 5: Well, every day can, I mean, there's just little things that happen that can be so rewarding. I kind of look at this line of work as a mission field. Mm-hmm. <affirmative>, you don't know what you're gonna walk into until you knock on the door. Like I said, one time I went in and a, a lady had her winter coat on and I was even cold. I [00:08:30] found out her electricity had been turned off and it was the middle of the winter. Mm-hmm. I wouldn't have known that if she had come into an office. So we called a line that we have called Advocate for me. We found out some resources in her area and you know, some people just get so depressed and so socially isolated that they don't know who to reach out to. Mm-hmm. <affirmative>. So she took the necessary paperwork and I checked on her the next day and she was able to get her electricity turned back on. Mm-hmm. Those are such rewarding things when you [00:09:00] feel like you've made a difference in somebody's life.
Speaker 2: Absolutely. I mean, that's amazing and it must feel so great for you to be able to make such a direct difference in people's lives. And as someone who's working so closely with the people that you're supporting, I'm wondering where you see the future of home-based care going?
Speaker 5: I think we're just gonna see it get bigger and bigger. People can order something and get it the next day at their front door. They can order their groceries. You can just about do anything in the home anymore. And it's, I think, just gonna [00:09:30] be the expected norm. I feel like it's something that people want and that they need is for you to meet them where they're at. Mm-hmm.
Speaker 4: <affirmative>. So with that being said, what's the reception that you're receiving from patients?
Speaker 5: So some of the patients we have, we've seen year after year, but some of the new people, they are a little skeptical. You're gonna come to my house and you're going to do labs and you know, so it's kind of a new concept for some of the new people. But [00:10:00] once they've had it, they're like, wow, I wanna do this every year. This is mm-hmm. <affirmative>, I love this. So yeah, it's just more people will talk about it and you know, some over 55 groups, they'll all get together and Oh yeah, you should have 'em come to your house. They do that and once they do, they're hooked.
Speaker 2: Yeah, that makes sense. And it's great to hear about how you're helping your patients. I also wanna talk about how you're helping your community. So can you tell us about the community food pantry you started? We hear that it's been running for almost 18 years [00:10:30] and serves a thousand people a week, which is amazing.
Speaker 5: Yeah, so it was 2005 and we started noticing people coming to our church that didn't have food. It started out as a little closet. We just had bags of food that we could just give out to people. We had 10 or 20 people coming, you know, for a few weeks, even a couple years. And then it just word got out, times got harder as time went on, especially 2008, [00:11:00] we really saw a rise in people coming to the pantry. So we were able to purchase a building next to the church. And yeah, we are having about 400 families a week that come in and get food. But if I can tell you the other side of that, it has been a good resource for me to get volunteers. If I go into a home and somebody's depressed or feeling isolated, I'll say, do you know about the pantry? Would you like to come and volunteer? Oh,
Speaker 4: Oh [00:11:30] wow.
Speaker 5: Okay. It is amazing to see how it's given them purpose. Huh? You feel so good inside. Mm-hmm. It's just a feeling you can't explain. It's
Speaker 4: Beautiful. Yeah. And I love how it all kind of intertwines together. Mm-hmm. <affirmative>. So this season we've talked a few different times in, you know, a few different angles about how community-based can really step up and fill in some of the gaps in care that exist within communities.
Speaker 2: [00:12:00] Yeah. And we um, we hear that you actually tell your house calls patients about the food shelf. So I'm wondering if you can say a little bit more about that and if there's any stories you could share.
Speaker 5: I will just keep a bag of groceries in my car and I will just say, no judgment at all. I run a food pantry and I have some food in my car. Is it okay if I bring it in? Mm-hmm. <affirmative> and they're glad to get that.
Speaker 2: Wow, that's so great.
Speaker 5: We had a guy, I saw him just a few months ago, told him about the food pantry [00:12:30] and he's a retired pastor. He came to the food pantry to get food and then he asked, is it okay if I just talk to people here and maybe pray with them if they need it? And we said, sure, absolutely. So I actually just saw him yesterday and he gave me a big hug when I saw him. And um, I feel like it's given him, you know, just a feeling of purpose and that he's not just getting a handout but he's giving back. Mm-hmm.
Speaker 2: <affirmative>. And what advice would you have for others [00:13:00] who might wanna volunteer at local organizations or get involved in community-based care?
Speaker 5: I would say absolutely, you know, you will not feel better Ben when you're helping somebody else. It's just at the end of the day when I've seen my members, if I'm able to do something that helps them, that is like icing on the cake.
Speaker 4: Hmm. Oh, that's good.
Speaker 2: Thank you Kim, for joining us today. We're gonna move into the lightning round. The first question is, what gives you hope?
Speaker 5: Hmm. Well I had [00:13:30] breast cancer about 12 years ago. I went into the doctor's office, he said, we're gonna start chemo on Friday. I went through several surgeries before we finally were able to hear the words. We got all the cancer live every day, like it's your last day. Mm-hmm. <affirmative>, you can impact so many people's lives. You know, not many people go through something like that where they don't know if they're gonna be able to make a difference, but just live that way. That's what keeps me going.
Speaker 4: Hmm. What's something [00:14:00] you've learned recently about yourself?
Speaker 5: That's a tough question. <laugh>, <laugh>. You know, when I was with my kids last night, they brought things to me that they see in me that I don't even see. So I guess it's just be an example to other people. So that's what I do try to do, but I don't even realize it. Mm-hmm.
Speaker 2: <affirmative>. And who is someone who's inspired you or had a really big impact on who you are today?
Speaker 5: I think my husband. We've been married for 40 years. I [00:14:30] didn't become a nurse until after we had our three children and it, it was really difficult to go to school. And then when I mentioned to go back to school to be an np, he was 100% behind me and pushing me and encouraging me. So he definitely inspires me.
Speaker 4: Hmm. That's great.
Speaker 2: Thank you so much for joining us today. This was such an incredible conversation. Thank
Speaker 1: You so much.
Speaker 2: So [00:15:00] what I really loved about this conversation with Kim is that she shares so much of her heart and it's clear it's not just a profession, it's something that she really genuinely cares about. I was particularly touched by her sharing that she drives around with a bag of food in her car and that she will bring that into the different people's homes that she works with and just the amount of care. It's a generosity of spirit that you really can't fake. Like that's not on her job requirement, [00:15:30] but it's something that she notices and she's paying attention to and she has a heart for. And I think that translates into her creating the food pantry, which also allows her to just deepen her relationships across community and also to provide opportunities for the people that she works with to come volunteer to like be connected to other people in their community too.
Speaker 2: The other thing I thought about is the fact that nurses drive 150 miles to give care that is so many miles. [00:16:00] And again, I just think it's like, you know, for the love of the game, it's like you have to really be in it. This is not something that people are doing just to collect a paycheck and clocking in and out. It is like a calling. I just really appreciated everything that she was able to share with us. For our next guest, Kenny and I had a chance to chat with Kristy Duffy. She is the Chief nursing Officer at Optum Health and Chief Operating Officer at Optum Home and Community Care. Let's listen in.
Speaker 4: [00:16:30] I am really excited to talk to you. I'm just really intrigued about care at home and community care, so thank you for giving us your time.
Speaker 1: Well, thanks for the opportunity to be here. It's something I'm very passionate about, so thank you. Well,
Speaker 4: To jump right in, can you give a little bit of your background and how you got interested in this type of work?
Speaker 1: Sure. So a little bit of my background. I've been a nurse for over [00:17:00] 25 years. I worked in the hospital setting and then went back to school to become a nurse practitioner. So I'm a board certified geriatric np. And when I graduated, worked in the skilled nursing facility and really bringing care to patients that are long-term, so average age in their eighties, multiple chronic conditions, really wanted to take care of patients before they hit the hospital <laugh>. And having to have those conversations in the hospital where we can have those conversations right in the skilled nursing facility. And then took a variety of roles. And actually I, I started [00:17:30] at UnitedHealthcare right outta grad school, left and went to a small startup called Xcel Health. And that's where house calls business actually started. And we started the business more bricks and mortar and found that when we were trying to get to people who live in underserved areas, remote areas, they didn't have transportation to get to the facilities, us to take care of them. And so that's where we brought house calls to them. And so we started that in about 2009. And then in 2012, Optum actually bought Xcel [00:18:00] Health and we've been able to take it to scale.
Speaker 4: Nice. So how does home-based care work? Who's the typical patient or consumer and who typically provides it?
Speaker 1: Yeah, so let me step back on coming community-based care business and what it is. Okay. So what the capabilities are and then how we're providing those services. So within Optum Health, we have a business called Home and Community, which is all community care-based business. So when I think about it, I think the easiest way to think about it is in four pillars. Mm-hmm. <affirmative>. So we have [00:18:30] the house calls business that I talked about where we have clinicians, primarily nps, nurse practitioners and physician assistants that go into patients homes. Primarily Medicare Advantage patients, Medicaid patients as well. And we do annual wellness visits. Mm-hmm. <affirmative>. And actually we are the largest provider of in-home visits in the United States. Last year we completed more than 2.29 million in-home visits. Mm-hmm. <affirmative>, our second pillar is care transitions. So when you think of a patient that goes from the hospital, what's the next site of service?
Speaker 1: Is that [00:19:00] in a skilled nursing facility? Is that in acute rehab or is that at home? Mm-hmm. <affirmative>. And so today we manage more than 10 million Americans from care transitions from hospital to next site of service. Mm-hmm. <affirmative> using multidisciplinary care teams to help with that post-discharge care plan, Kenny, so physical therapists, occupational therapists, nurses. The third pillar is our optimum home business, which is where we go into people's homes and we manage their care from social determinants of health, their mental health [00:19:30] and their physical health. And then the last bucket is our senior community care where we actually have clinicians in skilled nursing facilities, assisted living and senior housing. And so we're working together to ensure that we're bringing care to those people who need it the most. And what we found is more and more people want us in their home. Mm-hmm. <affirmative>.
Speaker 1: And what I would say is, I don't think gone are the days of bricks and mortar facility-based care, don't get me wrong, but I think as we think about what [00:20:00] we want, we want choice. We wanna have a choice of care, whether it's in an office, whether it's at home, or whether if it's virtual. Mm-hmm. <affirmative>, we have a fragmented healthcare system and people want care where they want it. And so for me that's a legacy I wanna leave my children and their children that we're gonna break down this fragmented care, this siloed care and give people choice really. Mm-hmm.
Speaker 2: <affirmative>. Yeah, I mean that seems like a really good example of meeting people where they're at in the different stages of their healthcare journeys. I'm also [00:20:30] wondering, it sounds like it's a lot to keep track of. So how does technology help?
Speaker 1: Yeah. I would say honestly we live and die by technology. I mean, at the end of the day today I have 11,000 clinicians in our home and community-based care team. When I talked about those four pillars, patient assessments, care transitions, senior community care, and Optum at home, we have to ensure that we are connected and that the information the clinicians needs are at their fingertips. But just talking about technology as well, I would say with the pandemic, with covid, [00:21:00] one of the things that was exciting about it is that we moved really fast and we saw everything as the glass half full versus app empty and we could do anything. And we stood up virtual visits like in a week, <laugh>. And what we're finding is people want that choice. Mm-hmm. We're also finding that people who live in remote or rural areas that don't have smartphones or smart devices, we're actually providing those devices for them so that 24 7 they can contact us and we can help them.
Speaker 1: We're also [00:21:30] using remote patient monitoring. I would say some of the other big challenges that we face with covid is in our skilled nursing facilities, that was really hit the hardest and they are very short staffed with clinicians and nurses. Mm-hmm. <affirmative>. And so we've done some things as far as robotics, putting robotics in a skilled nursing facility so that we can get an assessment on a patient and know what's happening real time. And then one other thing I wanna mention is we actually have rolled out something called Care Memo where we are connecting with caregivers [00:22:00] as well as patients and their primary care provider to have a clinical circle where we can share information and communicate with our entire care team via mobile app. So that's great. Really trying to stay on the cutting edge of how people wanna be connected.
Speaker 2: It is really great to see how technology is keeping people connected and making healthcare accessible. And I recently saw that Optum doubled the number of people serve through home-based care. So it was such a large impact. Can you speak to some of the outcomes [00:22:30] that you've seen so far?
Speaker 1: Yeah, actually we had a study published a few years ago about some of the outcomes and, and I'll just hit a couple of those. One is with our home-based care programs, we actually saw a 14% decrease in hospital admissions. We also saw an increase in primary care provider engagement up to 6% as well as a decrease in nursing home admissions. I would like to highlight though, when we think about some of the outcomes, which I'm really proud [00:23:00] about, when we think about health equity and getting to everyone mm-hmm. <affirmative>, because it doesn't matter where anyone lives, we're gonna get to them. And so last year alone, we actually completed over 395,000 in-home visits in rural counties, over 80,000 virtual visits. And we made more than 408,000 referrals. So when you think about going into someone's home, we're spending on average an hour with them. It's not six to eight minutes in an office. We have one hour one-on-one with that patient. That [00:23:30] family we're able to assess their environment, what's in their cupboards, do they have heat, do they have air conditioning, do they have electricity, do they have running water? I mean, if basic needs aren't met, we obviously know that health needs are not gonna be met. Yep.
Speaker 2: Those outcomes are really impressive. And as spreads about health at home, how is your team preparing to meet the growing demand?
Speaker 1: There is such a demand and it's supply. So when you think about 11,000 people aging into Medicare every single day, and by 20, 30, 70 3 million [00:24:00] people will be over the age of 65. Mm-hmm. <affirmative>, we have to focus on how do we have that supply. And what I would say to you, the biggest thing is we have to practice differently. We have to work in a team-based approach. And so that's what we've done with an Optum at home, where we have physicians, we have nurse practitioners, we have physical therapists, occupational therapists, behavioral health workers. We have to use the entire team. And that way we can get to everyone. [00:24:30] But what I would say is we do have a problem on our hands. We're seeing more physicians, retiring physicians coming outta school and going into specialty, not primary care. We're finding for nurse practitioners school and nursing school that there's not enough professors.
Speaker 1: And actually in 20 21, 90 1000 students were turned away because there weren't enough professors. Mm-hmm. <affirmative>, one thing that we're doing at United Health Group is we are actually partnering with universities and we today are standing up our own nurse [00:25:00] practitioner programs. Mm-hmm. <affirmative>, we are gonna be doing all of the training through Optum Health and we will be funding their tuition so that once they graduate, they have an opportunity to work at United Health Group. Mm-hmm. <affirmative>. And we are doing that with one university. And I have four more coming. And I would say the other thing is, as I'm starting to see more and more clinicians retire, having them give back as adjunct faculty to these universities to teach students mm-hmm. <affirmative>. So really trying to grow [00:25:30] our own so that we can get more and more people into this profession.
Speaker 2: Lastly, Christie, do you have any personal experience or stories that you might be willing to share about you or your family using home-based care?
Speaker 1: You know, I'm thinking about my son, he's 23, heard his back, and we had to go to the ER twice. We had to get admitted once just to get the care we needed because we couldn't get into a provider's office. Mm-hmm. <affirmative> and think about me, I mean, I'm in healthcare <laugh> and I can't even get an appointment. Yeah. If we had this home-based opportunity, we could have had him assessed [00:26:00] at home, we could had PT done at home, we could have missed two ER visits and got him back to work. And I think this is the next part of our journey, is how we can help people navigate their care.
Speaker 4: Great. Well that's a great way to cap things. So we have this thing called the lightning round. The first question is, what gives you hope?
Speaker 1: I would say what we do at United Health Group gives me hope. Okay. Because like I said earlier, I wanna make sure that we [00:26:30] can make healthcare as seamless as bordering a package. You know, it's, it shouldn't be as complicated. Yeah. And so that gives me hope as just the breadth and depth and the people that we can touch and what we change here. It's like no other. Yep.
Speaker 4: What about something that you've learned new recently?
Speaker 1: It's about self-care. I started meditating it, it was funny. I was, uh, I was in the airport like traveling like we do. And I saw this book Stress Less Accomplished More. And [00:27:00] um, so I've really been trying to hold myself to once a day, 10 minutes, just having my time Okay. To clear my head and I actually show up better versus the multitasking going from one thing to another. And so when we talk about wellness and wellbeing, that's something for me that helps me with my frame of mind and how I show up.
Speaker 4: Finally, who's someone who's inspired you or had a big impact on who you are and what you do today?
Speaker 1: My parents, I mean, my mom was a [00:27:30] secretary and worked in a doctor's office and my dad was an electrician and I used to go to the office and help my mom. And I'm the first to graduate from college. And so my parents inspired me to work hard. Uh, it's kind of funny, I went to University of South Carolina to pay for school. I worked at Piggly Wiggly. Mm-hmm. <affirmative>. Um, so you never forget where you come from and give back. And so for me it's, it's all about how do you, how do you give back to others?
Speaker 4: Great. No, I like that. And I'm excited to see how house calls evolves and you know, what's gonna happen with home and community. I think that it's [00:28:00] only good things going forward. Thank you for everything as well.
Speaker 2: I think it was really nice for me personally to hear two different perspectives on the same topic. And I think that the expanding need for home-based care is increasingly geared toward people being met where they're at. And that to me is such an exciting time for us to be in. So it's really cool to think about [00:28:30] the industry sort of stepping back to be like, wait a minute, how do we make it as easy as possible for people to receive what they need? And I think the outcomes of that in a couple years, hopefully sooner, are gonna be really exciting to see. Next week we'll be back to talk about the one thing that you can do today to help food shelves in your area, as well as to find support within your community. So thank you for listening. Thank you for joining. Make sure to follow and subscribe wherever you listen so that you can get notified when a new podcast episode is live. [00:29:00] And we'll catch you next time.