Editor’s Note: The following article is part of an ongoing series offering our strategic advice and expertise on what healthcare industry stakeholders should do immediately in response to the rapidly evolving novel coronavirus (COVID-19) pandemic.
As stay-at-home restrictions are lifting (in some areas, for now), people are starting to re-establish parts of their daily routine – including haircuts, dental appointments, and even dining. But a number of people are still home, still vulnerable, and still fearful. This is particularly true for seniors.
To learn more, we spoke to some leaders, clinicians, and social workers, at Landmark Health and its affiliated medical groups – an organization that delivers in-home primary care for high-need seniors – to help us understand what they saw on the front lines of caring for seniors during the height of the COVID-19 pandemic, the key lessons learned, and their concerns and suggestions for future waves of disease surge and quarantining.
Oliver Wyman: As of last March, over 60 million people were enrolled in a Medicare program – 25 million specifically in a Medicare Advantage plan. Some of these seniors are your patients. What was it like caring for the clinically vulnerable during stay-at-home restrictions?
Landmark Health: We bring geriatric medical care to the home for seniors – our physicians, nurse practitioners, and a supporting interdisciplinary team help patients manage their chronic conditions and solve the access issues that unnecessarily drive them to the hospital. Our model provides 24/7 care and this remained the case during “stay homes,” albeit with two key modifications:
First, how we delivered care shifted and our visit volume went up. To give you a sense, we conducted nearly 4,600 medical and behavioral health consults the last week of February – 100 percent of these were in person house calls. In contrast, we did nearly 5,300 consults the first week of April – only five percent of which were in-person with the balance done virtually (84 percent by phone and 11 percent by video). While telemedicine is a good complementary solution, one in three seniors still has difficulty using telemedicine due to discomfort with technology and certain health conditions (for example, hearing impairment and dementia). So we prioritized acquiring personal protective equipment (PPE) and getting back into the home as soon as possible. Seventy percent of our house calls are now back in the patient’s home – 20 percent telephonic, and 10 percent video.
Second, in a very meaningful way, the nature of the health issues we were dealing with changed. Our team developed a predictive algorithm to prioritize outreach to our most vulnerable patients at the start of the shutdown and we rapidly mobilized to proactively re-engage patients. As we did this, we saw an immediate need for help with social determinants of health issues and, over time, a gradual and growing need for urgent care services (some driven by individuals missing routine, preventative follow-up), behavioral health, and social work support.
Oliver Wyman: Social determinants of health have been a big area of focus in the industry over the last several years. Given its correlation with physical and behavioral health, how did these types of needs manifest differently during stay-at-home orders?
Landmark Health: The first and most obvious challenge was food insecurity if seniors were not comfortable (or physically able) to complete their normal grocery routines. This problem was compounded by changes in their support network during the shutdown (for example, canceled visits from family or paused church/community outreach programs). This issue came up quickly and frequently in our patient outreach and our social workers were able to help keep a pulse on which organizations were shuttered, and which new ones had popped up. They then navigated to connect our patients accordingly.
Interestingly – but not surprisingly – housing security did not come up as an issue. Frankly, some of the programs put in place to freeze evictions have helped our patients. If anything, there is a concern around whether our patients’ needs may extend beyond the lifecycle of COVID-specific programs (like eviction freezes or meal deliveries). This is something we are just going to have to keep an eye on.
One in three seniors still has difficulty using telemedicine
Oliver Wyman: Switching gears, regarding primary care, perhaps it was initially expected when the pandemic first began spreading that primary care would go down as more people were afraid to leave home. You saw something different, though, happening. What was the spike you saw?
Landmark Health: Initially, the demand for care was down, but over time, patients increasingly came to us to make up for missed care. Between temporary closure of traditional physician offices, patient concerns about the risk of visiting offices during this time, and tech challenges with video calls, our patients faced a number of barriers to care. As a result, we wrote more ongoing prescriptions and did more routine blood draws than normal to ensure the appropriate support to help our patients manage their conditions.
Oliver Wyman: That’s the critical question for us (and the industry and community): How much preventative care was missed? And is this going to show up in the pace or extent to which chronic conditions will escalate in the coming months? We have seen industry reports – like that in the Journal of the American College of Cardiology based on a study of nine high volume labs – that patients being treated for major artery blockages (known as STEMI) dropped 38 percent. That’s not likely because the need for these procedures has dropped.
Landmark Health: That’s a question we don’t yet have the full picture for from a data perspective – both at Landmark but also for the industry as a whole.
Here are a couple of observations from the frontline that may help us as an industry prepare for what’s to come:
When we got back in the home seeing our patients, we found the proportion of our care was different than a few months ago – rather than 60 percent routine care, 20 percent urgent, and 20 percent post-acute, it was looking more like 20 percent routine care, and 40 percent each of urgent and post-acute. Seemingly, people waited longer to address exacerbations and then refused nursing services out of fear, making recovery more difficult.
On the urgent care and even routine care front, a lot of what we have seen is tied to the worsening of chronic conditions when patients observe stay-at-home restrictions. Some of this is related to the lifestyle disruption we have all experienced. With patients stuck home and having irregular food access, their nutrition and exercise/mobility was worse, impacting patients’ diabetes and kidney functions. However, some of this is related to a hesitancy to engage with the healthcare system during the pandemic.
For example, we had congestive health failure (CHF) patients noticing rapid weight gain (a telltale sign that fluid is accumulating). Rather than seek care, they were gritting their teeth and trying to manage it on their own. Meanwhile, the fluid buildup put strain on their heart and kidneys and ultimately required attention. We would identify this need during our proactive telemedicine or home visits and then, in the case of CHF, administer diuretics. But the delay in seeking care typically meant the clinical intervention we had to perform was more intense and involved a longer recovery time. Granted, that’s better than what could happen in an untreated CHF case which could have resulted in sudden cardiac arrest or acute injury, but it’s still not the ideal situation for the patient.
If “stay-at-homes” either continue to be required or seniors self-select to continue their quarantine, we need to be careful about ensuring the adequacy of proactive, routine health screenings. This will be particularly important to identify emerging issues and avoid an increase in vascular disease, heart attacks, strokes, and the like.
We saw a 190 percent increase in behavioral health consults compared to pre-COVID
Oliver Wyman: You said behavioral health was an issue, too – that’s aligned with what we are hearing and seeing across the industry. What were the issues for seniors and how were they different from that of other populations?
Landmark Health: We saw a 190 percent increase in behavioral health consults compared to pre-COVID. A lot of the issues we were (and are) dealing with centered around loneliness, isolation, fear/anxiety, and depression, similar to other age groups. Our senior population’s support network was especially hard hit, though, and our patients often have greater difficulty taking advantage of technology for video sessions with friends or family.
For some of our seniors, close friends passed away in short succession. We’ve had some patients who lost four or five friends over the course of a few weeks. Others had to navigate the complexities of transmission between caregivers and dependents. There were a number of cases where patients with conditions like dementia were left on their own at home while a caregiver/spouse was in the hospital with COVID-19, and unable to move into assisted living facilities given exposure risk. Our social workers and providers did their best to navigate these situations and support both behavioral and physical health.
One small silver-lining was the increase in conversations around advanced directives planning. We found ourselves having more (and better) conversations with patients and caregivers around their goals and preferences for care they would receive if they were to become seriously ill (for example, the use of a ventilator or feeding tube). We completed 10,000 goals of care conversations in April alone. These conversations must be carefully navigated, but having better guidance and understanding on how patients want to be cared for is in everyone’s best interests.
Oliver Wyman: We’ve written about COVID-19’s silver linings – like telehealth’s recent boom, for instance. When you look to the future, what are the industry’s key learnings, tech and otherwise? What should insurers perhaps think about regarding future stay-at-home scenarios?
Landmark Health: First, making care and other services more readily available to seniors is not enough – insurers (and providers) have to find ways of getting care to the patient that works around any physical, geographic, or technology limitations. Many of the benefits that insurers are creating during this pandemic (such as free psychologist consultations or new telemedicine tools) are available, but not necessarily accessible for all their members because members didn’t know where to find them, how to use them, or were afraid to leave their home. From our experience, this pandemic has underscored the importance of the home as a site of care – allowing for a deeper contextual understanding of the patient (such as what kind of food they have access to) and literally meeting patients where they are.
Second, proactively check in on all members with chronic conditions – not just those who are already engaged in existing care management programs. With COVID-19 limiting access to care and creating the conditions for exacerbations (such as unhealthy eating, lack of exercise, and/or skipping medical care), chances are that members with chronic conditions are facing worsening health. Telephone calls or office visit coordination may not be enough – you need to find ways to send care to the member, as well.
Third, make behavioral health a part of all outreach. The stress of social isolation has reinforced or revealed existing behavioral health conditions for some (for example, hoarders), and for others, it has left a lasting mark with the breakdown of valued community connections. Fear and grief associated with the pandemic will likely outlast the “stay homes” and behavioral health check-ins will become an increasing part of both connecting with and caring for this population over the coming months.