Care Beyond Medicine: Addressing SDOH and Health Inequities in Marginalized Communities, with Mike Radu and Dr. Greg Foti

Mahatma Gandhi once said, The true measure of any society can be found in how it treats its most vulnerable members.”  The same can be said of healthcare organizations serving patients within their local communities.  In value-based care, the truest measure of any healthcare organization’s success (from both an economic and a moral imperative) is how it treats its most vulnerable patients.  It doesn’t get any clearer than that – serving the underserved…the 5% that drives 50% of medical spend…those that are dealing with serious illness due to chronic disease, mental health issues, or substance abuse is the most important focus we should all have as an industry. And with this intersection between vulnerability and minoritized populations, we have to start thinking about value-based care and health equity as one and the same. 

In this week’s episode, we are joined by two mavens, Michael Radu, CEO, and Dr. Gregory Foti, Chief Medical and Transformation Officer of AbsoluteCare. AbsoluteCare, is a leading innovator in patient-centered, value-based care. They are what I would call an integrated Chronic Care Patient Centered Ambulatory ICU that partners with health plans to care for only the most vulnerable complex patients. They are similar to other high-touch, relationship-based primary care centers; however, they don’t spread risk by accepting global capitation within the entirety of a normalized managed population, including caring for those who are relatively healthy.  AbsoluteCARE sees only the sickest of the sick, and they are getting positive results with their comprehensive multidisciplinary care model by focusing on all aspects of a patient’s life issues – social, behavioral, substance use disorders and medical – to give patients the resources they need to fully change their lives. Listen today to learn from these leaders in the race to value!

Episode Bookmarks:

05:00 The AbsoluteCare Care Model and its clinical and utilization impressive outcomes

07:00 Dr. Greg Foti explains his personal “Why” and how his disillusionment with FFS made him a champion for value-based care

08:20 Building trust with members as the “secret sauce” and why it is important for clinicians to take time to listen

09:45 How relationship-based care supports SDOH interventions and closing gaps in care

10:25 Mike Radu discusses how AbsoluteCare takes time with patients by lowering the patient panel per clinician and adding support teams

12:00 Promoting literacy and understanding of care plan and discharge instructions with post-visit follow-up from care team coordinator

12:50 Social workers and RNs as an additional wraparound support model to enhance member outcomes

13:45 “Beyond Medicine” and SDOH – an example of how AbsoluteCare helped a member overcome housing instability

15:45 Focusing on the top 4-6% of highest utilizers within the most vulnerable, complex, marginalized populations

16:50 Dr. Foti describes how AbsoluteCare provides housing interventions and build partnerships with communities and health plans

18:30 Addressing food insecurity through food bank partnerships and a “food as medicine” strategy

19:05 Helping members dealing with social isolation by building a community-based outreach structure

20:00 Mike Radu provides additional context on AbsoluteCare helps members dealing with food insecurity, housing instability, and health illiteracy

22:00 Using Member Rewards (re-loadable gift cards) that incentivizes members to engage in their own health

23:10 Dr. Foti discusses how innovative care delivery is only possible with value-based contracts that provide prospective funding for investments

24:30 “Dismantling the fence” in society to remove barriers (such as institutional racism and SDOH) that create inequities

27:00 Mike Radu provides perspective from his time with CMMI on how value-based care innovation is solving for health equity

29:30 The need for CMS to innovate Risk Adjustment methodology to include SDOH data

30:30 Measurement of impact (e.g. ER diversion, rehospitalizations) is needed to justify value-based care program investments

31:00 Reporting voluntary Z codes to capture SDOH data and how AbsoluteCare uses them for risk stratification and attribution logic

32:00 “Our North Star is to change the trajectory of a child’s life and address health equity for the next generation.”

34:00 The importance of culturally competent care to better connect with complex populations in minoritized communities

35:30 How AbsoluteCare provides transgender care through trust building and culturally competent care

36:45 Building health centers only in those communities most in need and the importance of recruiting employees from those communities

39:40 Suboptimal health literacy is an independent risk factor for poor health outcomes, including increased risk of hospitalization.

41:00 Dr. Foti describes the difficulties in navigating the healthcare system and why care coordination is needed (especially for most vulnerable)

43:00 Using information exchanges and ADT feeds to provide alerts to Interdisciplinary care team

44:00 “Hub and Spoke” care model (health centers and embedded community-based care teams)

44:45 How AbsoluteCare approaches integration of behavioral health and pharmacy within primary care model

46:00 Infusion Center for acute care treatment of chronic disease exacerbation

47:45 In-house Laboratory to support members at the point-of-care

49:00 Workforce development for all care team members and the importance of daily team huddles

51:00 Mike Radu describes the data and analytics infrastructure at AbsoluteCare

53:00 Transportation services to pick up members for primary care visits and also delivery medications to their home

54:15 The need for complex medication review (average member has 13 diagnoses and 10 medications)

55:30 Dr. Foti fully describes the integrated pharmacy model at AbsoluteCare

61:00 Dr. Foti fully describes behavioral health integration (Collaborative Care Model) at AbsoluteCare

66:00 Mike Radu on how AbsoluteCare leverages complex algorithms to drive community-based interventions

69:30 Entrenched economic interests and the difficulty of burning the ships to settle in the “New World” of value-based care

71:00 A reason for optimism in the value movement