Presbyterian Healthcare Services has been reaching out to high-risk individuals and families to try to get ahead of complications stemming from COVID-19.
The Albuquerque-based integrated health system has analyzed electronic health record and health plan data to identify older populations, people with chronic diseases as well as families that don’t have access to quality food, among other social barriers. It has contacted more than 30,000 health plan members since March to make sure they were taking their medicine, keeping appointments, eating well and to ask if they had any questions about accessing care.
A Presbyterian Health Plan community worker recently reached out to a family of three—a 2-year-old who tested positive for COVID-19; his grandmother; and mother, who is out of work. They are now getting meals delivered to them, financial aid for their utilities and guidance on how to use transportation and telehealth services, helping them stay healthy and out of the hospital, said Dr. Gray Clarke, medical director for Presbyterian Health Plan.
“We have delivered almost 3,000 meals to date, with the help of Meals on Wheels,” she said, noting that the nutrition program was part of a social determinants of health effort implemented prior to the pandemic. For the cost of meals, the health plan pays $207 per member; it also provides 14 days of meals for one caregiver.
New Mexico’s three biggest systems, like many across the country, have been over capacity—both for inpatient and intensive-care beds—for the past two weeks. But lessons learned from the first wave, along with data analysis, have helped providers revamp outreach efforts and streamline treatment pathways, resulting in shorter stints in the hospital and fewer readmissions, as well as better resource allocation.
“We hope to get an outpatient remdesivir infusion clinic up and running by Dec. 1, which should make a huge difference,” said Dr. Jason Mitchell, chief medical officer of Presbyterian Healthcare Services. “We stratify who is highest risk and make sure they have their refills done, switch them to mail order, convert appointments to video visits and that they are managing their chronic conditions. That has had a profound impact.”
In New Mexico, the number of COVID-19 cases has nearly doubled in the past month, requiring another all-hands-on-deck response, per Johns Hopkins University data. Most states have fewer than 30% of their ICU beds available, according to HHS data, although those are often conservative estimates since hospitals may have added capacity and often don’t have the staff to manage additional beds, Mitchell said.
Presbyterian Health Plan has lifted the prior authorization requirement of some medication refills, which has improved adherence and lessened clinicians’ paperwork. Administrators have halted nonurgent surgeries, and trained and redeployed outpatient workers as well as back-office employees in their hospitals. Hospitals in Illinois, where cases have been ballooning by more than 10,000 a day, are also starting to roll back elective procedures. Similar scenarios are playing out across the nation.
Hospital leaders say they are better prepared for the latest spike, in part thanks to their data analysis.
Acute COVID-19 patients commonly have underlying chronic conditions. Providers hope that new data from FAIR Health showing which comorbidities present the most risk could help them hone their risk-stratification, and help prioritize interventions and vaccination distribution.
“It is tremendously important to say this is the stratification of patients that we need to take a hard look at to try to keep them out of the hospital, or if they are in the hospital, optimize treatment as soon as possible,” said David Pearce, president of research and innovation at Sioux Falls, S.D.-based Sanford Health, who lauded FAIR Health’s research and noted that it matched up with Sanford’s.
When a high-risk individual is COVID-19 positive and does not require acute care, Sanford sets them up with a blood-oxygen level home-monitoring kit. Once those levels hit a certain threshold, they should see their doctor, hopefully heading off complications that would require hospitalization, Pearce said.
AdventHealth, which is based in Florida, where cases have increased by about 20% over the past month, has mobilized nursing teams that have helped treat around 8,000 patients in their homes.
FAIR Health’s analysis of more than 467,000 private insurance claims from April through August revealed that developmental disorders present the most risk across all age groups. Those who had disorders involving speech and language, scholastic skills, central auditory processing, among others, were three times more likely to die from COVID-19 than patients who had the virus but did not have developmental disorders.
