Providing a Safety Net for Vulnerable Patients During COVID-19

Imagine you’re 80 years old, living alone in a beautiful, but expensive metropolitan area. Sometimes you have trouble affording your prescriptions, and the pandemic has made it difficult, even frightening, to get to the pharmacy. Then, you get a call from a case worker at your doctor’s office asking how they can help.

Contra Costa treats many lower-income patients and underserved populations in the San Francisco Bay Area, and these patients have a higher risk for serious complications from COVID-19. Care managers proactively address patients’ social needs to reduce their exposure to the virus and help them stay healthy.

“We wanted to proactively support our patients during the pandemic,” said Daniel Brown, MPH, PhD, a data scientist who helped Contra Costa find high-risk patients. “That means addressing patients’ needs for food, medication, and access to care so they can safely shelter in place.”

To identify these patients, Contra Costa uses a predictive risk score to evaluate a patient’s likelihood of severe complications from a respiratory disease like the flu or COVID-19. Each patient’s risk is calculated based on factors in the Epic chart, such as age and previous hospitalizations.

Case managers call high-risk patients to educate them about local health guidelines and ask about their access to food, medication, and healthcare. The calls are documented in Epic so the care team can follow up.

For example, care managers found that many patients were eligible for longer-term prescription fills and worked with providers to update 40% of prescriptions. By reducing the need for patients to visit the pharmacy, they eliminated thousands of potential exposures. Contra Costa also partnered with local food banks and county transit providers to provide patients with delivered meals.

Epic community members can learn more from Contra Costa’s webinar recording on the UserWeb. More information about using risk scores is available in the Managing Coronavirus Disease 2019 (COVID-19) With Epic documentation on the UserWeb.