Care Management for the Vulnerable: MHN’s Proactive COVID-19 Work

One of the many early lessons learned from the COVID-19 pandemic is that the outbreak is hitting certain communities much harder than others. For example, recent CDC data revealed a disproportionate burden of illness and death among racial and ethnic minority groups, referencing an internal report finding that out of a sample of 580 hospitalized patients with lab-confirmed COVID-19, 33 percent of hospitalized patients were black compared to 18 percent who were black in the community. For white patients, however, the data told a different story; the report found that 45 percent of individuals in the sample were white, compared to 55 percent in the surrounding community.

According to the CDC, “Health differences between racial and ethnic groups are often due to economic and social conditions that are more common among some racial and ethnic minorities than whites.” In the context of the pandemic, racial and ethnic minorities may be more likely to live in densely populated areas, making it tougher to socially distance. These groups of people are also more likely to live in multi-generational households, and be considered “essential workers,” further limiting their ability to stay home.

Undoubtedly, for COVID-confirmed or suspected individuals, being able to safely quarantine is vital to improving their health, as well as to ensuring the safety of others. But for vulnerable populations, accomplishing this can be challenging, and the ability to stay home requires care and resources that are necessary to contain the virus from spreading.

To that end, Cook County, Ill., is the most populous county in the state and the second most populous in the U.S., behind only Los Angeles County. Nearly half of the population are Hispanic or black. For Medicaid beneficiaries in Cook County, understanding what measures to take to protect against or receive treatment for COVID-19 can be overwhelming if they are facing barriers, such as homelessness or lack of access to transportation.

Indeed, when a patient gets a COVID-19 test, hospitals may not receive COVID-19 test results for days and therefore, depending on the patient’s symptoms—and capacity of the hospital—they may be sent home, along with many others not considered severe enough to qualify for a test. During that waiting period, patients may be leaving their homes, interacting with family members and unknowingly infecting others, despite the “shelter-in-place” guidelines.

“Safety net patients often do not have support at home—and are likely to go to the grocery store themselves – which is the last thing we want people doing,” says Art Jones, M.D., chief medical officer at Medical Home Network (MHN), a Chicago-based collaborative whose accountable care organization (MHN ACO) provides care to approximately 120,000 Medicaid patients in Cook County.

In all, MHN connects 30 hospitals with more than 400 primary care medical homes, behavioral health and community-based organizations through its platform, MHNConnect, in service of more than 320,000 Medicaid patients in Cook County. Its leaders firmly believe that earlier notification of suspect cases among this vulnerable group can have a significant impact on “flattening the curve,” but also surveillance for the broader community in the county.

MHN’s patient population is comprised of individuals with significant social needs. For example, as Cheryl Lulias, president and CEO at Medical Home Network, explains, in the population the organization manages through its MHN ACO, between 10,000 and 15,000 patients are socially isolated without friends or family to care for them. “These are high-priority patients to outreach to and to enable connections to care or resources. This is an example of social determinants that are more prevalent in underserved communities, and by addressing those determinants, we are able to prioritize outreach lists for our care teams, which will be impactful since these are people who need support,” she says.

What’s more, Jones reiterates that much of MHN’s patient population lives in crowded quarters and are considered essential workers, meaning they are more likely to take public transportation to work. They are also at high-risk for getting infected and for complications, since obesity and heart and lung problems are more prevalent in this community. “So if they do get infected they’re more likely to have an adverse outcome. And their social situations mean that the virus will be much more likely to spread,” he says.

As such, recently, MHN leaders were able to identify patterns of diagnosis codes with real-time patient hospital visit data for suspect COVID-19 cases. Using this algorithm, they are pushing real-time admission, discharge, and transfer (ADT) notifications and tagging potential COVID patients to front-line care teams across Cook County.

Lulias notes that her team has been working to augment ADT alerts they already had implemented with data on COVID-confirmed and suspected patients that started to come in. They then started map that information to CDC guidelines, with the end goal being to “engage our care teams to enable proactive education, outreach, care management, and connection to resources” for suspected or confirmed COVID patients who present at the ED. Adds Jones, “Community care teams can help bridge that gap, mobilize resources and ultimately, protect the community during this holding period.”

Jones contends that the alerts serve multiple purposes. For one, if MHN gets notified that a patient has presented to the ER, its care team can help educate that individual that going to the emergency room is likely unnecessary, especially if he or she is standing on line to get inside, thus increasing the risk of spread. “If they didn’t have the virus when they were standing in line at the ER, there is a high chance they’d get it by the time they came out,” says Jones.

Secondly, he believes there is need to follow-up during the waiting period of getting test results back; if the patient did test positive, MHN wants to follow up with that individual about what they should be doing to reduce the chance they infect someone else. “We also want to tell people that if they do develop symptoms again, they can use telehealth rather than going to stand in line or call 911 and further burden the first responders. Our practices have all rapidly pivoted to telehealth, but that doesn’t mean that our patient population knew they could access services that way,” Jones says.

To this end, MHN has also been working with ClosedLoop.ai, which develops a healthcare data science platform, to use the company’s COVID-19 Vulnerability Index—an artificial intelligence (AI)-based predictive model. The platform is used in combination with MHN ACO's patient demographics, SDOH claims and clinical activity to create a predictive model that allows MHN to prioritize care management outreach to patients who are likely to have a heightened vulnerability to severe complications from COVID-19.

How are the outreach efforts progressing? Lulias notes that from the worklist her team created, MHN had approximately 16,000 members that were targeted as high-risk based on their social determinants, of which the organization’s care teams has reached out to 5,700 so far. “So we are connecting people to care and providing education, access to telehealth, and enabled chronic care management during a pandemic,” she says.

And then there are the personal stories on the ground, Lulias adds, remarking how grateful some people are—particularly those who live alone—that people care about them. “One of our care team recently workers got a call from a primary care physician just saying ‘thank you for calling my patient,’” she recalls.