Amongst public and private healthcare, health plans and providers, new opportunities for collaboration are arising during the COVID-19 pandemic. Care is being reprioritized and new best practices continue to emerge. Private-public partnerships have evolved to identify individuals at high risk for poor outcomes directly or indirectly related to COVID, evaluate the impact of social determinants of health (SDOH) on patient outcomes, and address the impacts of social isolation.
I was recently interviewed by HIMSS TV to discuss how HealthEC’s CareConnect population health solution supports effective patient risk stratification, outreach, and care coordination for persons identified at highest-risk of severe COVID infection.
Early experience revealed that age >65 years and multiple underlying chronic conditions were significant risk factors for COVID infection. However, 100% outreach to the entire Medicare and Medicaid population is unrealistic and impractical. A more targeted approach is necessary. During the interview with Susan Morse, Managing Editor, Healthcare Finance News, I shared best practices for effective, targeted COVID-19 patient outreach. These include:
- Apply AI, machine learning, and predictive analytics to your population health data
- Stratify data to identify the top 10% (or 1%) of highest-risk patients
- Provide dashboards for care managers supporting patient outreach via phone calls or telehealth which can seamlessly be incorporated into existing workflows
- Build specific COVID-19 surveys to identify symptoms requiring urgent evaluation, provide on-going management of co-morbidities, and assess need for social supports including mental health, etc.
- Identify and manage patients who can safely remain at home utilizing telehealth and other services
- Recommend more intensive interventions when indicated
We explored the many issues pertaining to outreach for homeless and other underserved, vulnerable populations. Difficulty practicing social distancing (i.e., living in shelters or encampments, large apartment complexes or overcrowed apartments), aversion to seeking medical treatment, and lack of access to a computer, smart phone, or private transportation are only a few of the many challenges. Boots on the ground by community workers is often the only option. Establishing trust between these professionals and the community is essential.
We also examined critical racial disparities in COVID-19 infection and mortality rates, as well as in the community response and mitigation efforts. There are no easy answers but data collection, analysis, and dissemination of these data are essential first steps to effecting change.
Finally, we briefly considered potential positive outcomes of this pandemic regarding our healthcare delivery system in the U.S. vis-à-vis reducing unnecessary emergency department admissions, encouraging use of telehealth, etc.. What new lessons will our industry learn through this experience?
