Pandemic Requires New Approaches to Patients with Complex Needs
As the pandemic continues, healthcare organizations that focus on caring for patients with complex care conditions are learning lessons from their proactive outreach to patients and primary care providers as well as community-based organizations.
OneCare Vermont, the statewide accountable care organization (ACO) in the Green Mountain State, developed a COVID-19 care coordination prioritization application. During an Aug. 31 webinar put on by the Center for Health Care Strategies, Tyler Gauthier, OneCare’s director of value-based care, noted that OneCare has 250,000 Vermonters in active risk-based contracts, out of a statewide population of approximately 630,000. All the care partners in the ACO participate in a complex care coordination program. When the pandemic hit, OneCare set out to create a way for primary care providers to proactively identify patients who may be at the highest risk. They created a self-service analytics tool that takes guidance from reputable organizations and creates something easy to use so they could reach out those most at risk.
A primary care provider office can see all of their patients in list form and then select criteria such as age and any chronic conditions or frailty that put them at extra risk or frail. That includes frequent users of the emergency room and patients with mental health or substance use disorders. “We also identify patients with high social complexity risk, including issues of food access or social isolation,” Gauthier said. “We also work with our HIE to bring in COVID results, so providers can get information on whether patients have tested positive or not.”
They can also get additional details on a patient, such as inpatient admissions in the last 12 months, and how many ED visits.
The presentation quoted Norman Ward, OneCare’s chief medical officer and a family physician: “I went on the new COVID app yesterday for my own patients and it really was successful at surfacing the riskiest people, some of whom I might not have thought of without the tool.”
Redesigning behavioral health screening
In the Bronx, Montefiore Medical Group’s Pediatric Behavioral Health Integration Program (BHIP) had to rapidly redesign screening processes during the COVID-19 crisis. Miguelina Germán, Ph.D., director of pediatric behavioral health services, and Teresa Hsu-Walklet, Ph.D., director of clinical operations in pediatric behavioral health services, described the challenge. They had to manage behavioral health referrals with fewer clinicians, because many clinicians were pulled into serve in inpatient settings during the surge. They were charged with keeping patients out of the Emergency Department and hospital, yet a majority of well-child visits were suspended, which vastly disrupted their behavioral health screening process.
To cope, they built a telehealth platform in a matter of weeks. Montefiore also developed a triage and COVID short screening process that broke down silos between the pediatric and adult treatment programs.
The team used waivers and telehealth to decentralize the provision of treatment. They were able to e-mail patients with fewer encryption requirements in order to maximize their clinicians’ ability to send resources to patients.
Text messaging in Brooklyn
During the same webinar, Maimonides Medical Center executives described a pilot project to engage patients through text messages during the height of the pandemic. The Brooklyn Health Home (BHH) is a Maimonides-managed entity that provides community-based care management services to Medicaid patients with multiple chronic medical and behavioral health conditions, serious mental illness and/or HIV/AIDS, with functional impairments and social determinants of health.
Its network is comprised of 20 care management agencies, including hospitals, community-based organizations, and social service providers that identify and address a full range of behavioral, medical, and social problems affecting chronically ill patients. BHH currently provides services to over 8,000 individuals across Brooklyn.
Danielle Cuyuch, senior director of population health program integration, said a New York City COVID-19 Rapid Response Coalition, a cross-sector collaboration with leaders from social services, healthcare and technology, had just formed and offered to help. The effort had pro bono project management from Bain & Company, tech expertise & solutions from Amazon Web Services, and guidance from Manatt, Phelps & Phillips, LLP.
“We connected all members who responded to text messages to a care manager to address identified needs,” Cuyuch said.
Brian Pisano, manager of IT implementation and support, explained how the texting app was built. An Amazone Web Services Professional Services team built an SMS-based chatbot platform for proactive and light-touch member outreach. It was designed as a “Wellness Check In” text, in English or Spanish, he said. It leveraged Amazon Pinpoint, a highly scalable and globally distributed SMS service; Amazon Lex, a service for building conversational interfaces uses voice and text; and Amazon Connect, an omnichannel cloud contact center that directly connected members to managed call centers and other resources
Cuyuch noted that 11 percent of the 5,605 members texted responded. Their findings include that 77 percent said they needed help, and 87 percent of respondents identified food, unemployment, or housing needs. In addition:
• 25% indicated need for emotional or mental health support;
• 23% reported COVID symptoms or concerns;
• 17% reported having trouble reaching their doctor for urgent health needs; and
• 13% indicated problems getting medication.
The text pilot surfaced critical issues and allowed care manager and health home to mobilize supportive services, she said. It also served as a way to re-engage with some patients. Although it proved an efficient way to communicate and assess the needs of a large group of members, it posed challenges given that it is not integrated with the EHR. She said additional analysis is under way to learn which of BHH’s patients are best served by this type of intervention. It has possible application as a suicide prevention intervention, she said.
