Optum Health Chief Nursing Officer: In-Home Care Opens Door to Longitudinal Support, Offers Critical SDoH Visibility

In-home care and health assessments give payers and providers the ability to better manage vulnerable populations while addressing social determinants of health (SDoH).

That’s partly why UnitedHealth Group (NYSE: UNH) subsidiary Optum has invested so mightily in its home- and community-based care efforts, including its HouseCalls program, according to Optum Health Chief Nursing Officer Kristy Duffey.

“I really believe care in the home is the solution to getting the right care, at the right time, to the people who need it most,” Duffey said, speaking during a recent NEJM Catalyst event.


In addition to her position as chief nursing officer, Duffey holds the COO role for Optum Home & Community Care, which administers the HouseCalls program.

“I would like to just underscore that people’s homes are really where health decisions are made on a daily basis,” she added.

Optum HouseCalls is available in all 50 states. Through the program, Optum sends advanced practice clinicians into Medicare beneficiaries’ homes for comprehensive health assessments, with the service also available virtually.


During those visits, Optum HouseCalls clinicians check up on Medicare beneficiaries to make sure they’re managing their medications and following their care plans. They also monitor for possible SDoH barriers, such as transportation challenges, poor nutrition, financial hardship and social isolation.

“When we think about our in-home programs and our initial in-home visits with Optum, I believe that it opens the door to longitudinal support from an interdisciplinary interdisciplinary care team, supporting the patients through their transitions of care as well as helping the patient navigate their care,” Duffey continued.

In 2022, the Optum HouseCalls program made more than 395,000 visits in rural communities and over 80,000 virtual visits. In total, the program screened more than 2 million individuals for SDoH challenges, ultimately making over 408,000 SDoH-related referrals.

“I’m not saying that office visits are going to go away,” Duffey said. “But I truly believe that home care is one leg to the stool – and that health care is not one size fits all.”

Generally, neither health plans nor providers have screened for SDoH in the past as a standard practice, according to Duffey. Doing so at Optum allows the organization to be more “proactive” than “reactive,” she said.

As far as outcomes, home assessments such as the Optum HouseCalls program have been found to decrease hospital admissions by up to 14% while also increasing physician office visits by up to 6%.

Optum sees so much value in SDoH that it now includes SDoH as part of its risk-stratification of patients.

“Historically, payers and plans have not done that,” Duffey said.

Moving forward, Optum leaders will need to figure out how the HouseCalls program best works alongside the organization’s other in-home care capabilities, including the legacy home health and hospice operations of LHC Group. Optum finalized its acquisition of LHC Group on Feb. 22.

Optum is also in the bidding to acquire home health and hospice giant Amedisys Inc. (Nasdaq: AMED). Amedisys previously entered into a merger agreement with Option Care Health (Nasdaq: OPCH).

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