As accountable care organizations (ACOs) consider options for advancing their population health initiatives in the midst of the coronavirus pandemic, some organizations are choosing to opt-out of risk based programs for 2020, some are staying in and putting proactive activities on hold but some are carrying the mantle of population health forward, to serve patient needs in this time. For organizations that are truly invested in a long-term population health strategy, there is a need to continue to proactively manage patients, even as traditional medical services are disrupted. As noted in the Professional Case Management Journal, this pandemic has provided opportunities for innovation and creativity including use of digital and telecommunication technology in new ways to ensure the continued delivery of health and to those who need them regardless of location. This is consistent with what we have heard from several client organizations, and we wanted to share their ideas and strategies with you.  

The Care Coordination Institute (CCI) in Greenville, SC (affiliated with Prisma Health), is maximizing patients’ ability to interface with providers to care for their chronic conditions at home. In response to the pandemic, CCI has implemented new strategies for monitoring chronic condition health, for example, asking patients to enter daily blood glucose results electronically for care manager review.  In order to making sure that chronic condition patients still receive the care they need when unable to attend an in-person visit or worried about presenting in person, CCI implemented a Virtual Visit for Chronic Condition patient strategy, focusing first on the highest risk patients. Additionally, they have creatively adapted the in-vehicle COVID-19 testing model and created a new drive-through blood pressure monitoring and lab draw clinic. Pushing the boundaries of preventive care that patients can receive at home, CCI is helping physician practices send patients Cologuard® tests to complete at home. Finally, CCI is partnering with chronic condition patients to develop solutions to their medication adherence challenges. While these programs were developed to mitigate the virtual transmission risks of in-person healthcare services  while facilitating continued access to necessary care during the coronavirus pandemic, CCI is evaluating whether some should last for the longer term; for example, both patients and providers have high rates of satisfaction with virtual visits.

The coronavirus pandemic hit New York City-based Mt. Sinai Health System hard, but they were determined to continue their focus on proactive outreach to their attributed patients. The population health team at Mt. Sinai recognized that patients were reluctant to engage in- person with the healthcare system because of fears of COVID-19, and that the population health team was uniquely positioned to conduct a campaign of proactive outreach to ensure patients’ needs were being met. First, they conducted an outreach campaign to all patients currently enrolled in care management to discuss their needs. From that initial outreach, they identified five key themes:

• Chronic condition management
• Pharmaceutical access
• Food insecurity
• Behavioral health – exacerbated by financial distress, social isolation, etc.
• And finally, COVID-19 related symptoms

Mt. Sinai then expanded their outreach to include a broader set of at-risk patients. They created a list of patients at high-risk during the pandemic, including patients that are immunosuppressed or have heart disease, COPD, or other select conditions. They paired this patient list with the development of a resource guide that provides a description of resources to help address each of the key themes. Then, Mt. Sinai’s care coordinators, or where possible, their primary care physician’s staff, contacted these high-risk patients and leveraged the resource guide to help resolve their issues. Outreach staff reported higher than typical level of engagement in these calls, as patients were largely home, in need, and had questions about their health.

Both CCI and Mt. Sinai have adapted quickly to adopt telehealth. Mt. Sinai is currently completing more telehealth visits each day as they completed across the whole of 2019. Additionally, the team at CCI tells us that both patients and providers have grown to support the telehealth model, and they are hopeful that enhanced reimbursement for telehealth will remain after the crisis is over. CCI is considering continuing some of their remote initiatives anyway, recognizing the benefit of enhanced population healthcare. It is possible that some of the innovative initiatives these organizations are deploying today will have longer-term benefits in their overall population health strategy.