‘Micro Social Determinants of Health’ Tool Helps Senior Helpers Reach 3% Re-Hospitalization Rate


Although social determinants of health play a key role in outcomes, the health care industry often struggles with how to address social factors because they fall outside of traditional clinical care.

Home care providers are in a good position to help — and Senior Helpers, an international home care franchise with more than 300 locations worldwide, is doing just that. Senior Helpers recently began implementing the Life, Independence, Function, Evaluation (LIFE) Profile assessment tool to enhance its care planning.

LIFE Profile is a data-driven assessment tool that helps identify what the Baltimore-based franchise company calls “micro social determinants of health.” Specifically, the assessment’s findings are used to put together defined care plans for Senior Helper clients coming home from a skilled nursing facility (SNF).

Operationally, the LIFE Profile tool uses a five-factor framework, which includes daily living activities (ADLs), home safety, medical condition management, caregiver stress and quality of life. Each factor produces a score based on the client’s circumstances.

“LIFE Profile is a five-factor framework that is based on 18 years of research into the causes of hospital readmission,” Peter Ross, CEO and co-founder of Senior Helpers, told Home Health Care News. “We want to keep seniors at home. We want to keep them out of the hospital, and I think looking at this kind of assessment helps to deliver a model of care that’s the right level of support.”

Broadly, social determinants of health are socioeconomic and environmental factors that impact differences in health status.

Meanwhile, micro social determinants of health — a term coined by the company — are factors specific to a person.

Data for MA plans

Senior Helpers’ use of the LIFE Profile assessment tool is reflective of the industry’s willingness to ramp up data-collection efforts, a basic requirement for working with potential Medicare Advantage (MA) partners.

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One area, in particular, that Senior Helpers focuses on with the tool is home safety.

As part of the LIFE Profile assessment, the company performs an environmental review and overall home safety check for each client. During such a safety check, the company may discover that a client’s doorway is not wide enough for his or her walker — an example of a micro social determinants of health.

“We really look at that non-clinical side to understand what factors are impacting that client,” Ross said. “We do a complete home-safety check, which a lot of home care companies really don’t do. We look into details regarding throw rugs, clutter, bathrooms, the height of cabinets and areas where falls can be prevented.”

Traditionally, care planning assessments in home care were not always as holistic or comprehensive, according to Ross.

“In home care, for years, our assessments were, ‘Okay, you take these medications. Take them at this time of day. We will make sure you get food at this time. We will make sure you go to the doctor and keep the house clean,’” he said. “[We’re] beyond that now. This really takes a look at where that person is at in their life and how we can improve on that — and overall health.”

As far as results, clients assessed with the LIFE Profile tool and given corresponding care plans designed for them saw a 30-day readmission rate of 3%, according to Senior Helpers data. That’s compared to the national average of more than 21%.

Results like that will be especially appealing to MA plans looking to contract with home care providers.

“We believe that having access to this data can make a real difference when it comes to understanding outcomes,” Ross said. “Home care has never really talked a lot about outcomes and data. Home health, long-term care facilities and hospice [agencies] get star-rated based on outcomes and quality marks, and that’s never been in the DNA of home care. That’s always worried me as an industry leader.”

For now, Senior Helpers is looking toward technology to further improve the LIFE Profile tool.

For instance, the company is in the process of finalizing an app that will help care managers automate the assessment-scoring process. In the past, the company relied on notes and excel spreadsheets to accomplish the task.

“We are trying to automate with this app,” Ross said. “It will provide a great resource and make that intake much easier. It will also give us the ability to measure assessments across the country. It will allow us to look at real-time scores and outcomes.”

In the future, Senior Helpers thinks that collecting individual-level data on social determinants of health — like LIFE Profiles does — will become an industry best practice.

“We will be able to cross-reference that with demographics, disease state, and it might be very interesting to see what the accumulation of this data will mean over time,” Michael Hughes, vice president of strategic development for Senior Helpers, told HHCN. “Because we are able to score people, we will be able to see what types of care plans are effective in moving the needle.”



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