Medical Home Network Uses AI to Identify High-Risk COVID-19 Patients

Medical Home Network (MHN), a Chicago-based healthcare organization, is building on its predictive health risk screening approach to identify Medicaid patients who are at the most risk from COVID-19.

Officials of the organization, which also operates a provider-owned accountable care organization (ACO), noted in a recent announcement that for Medicaid beneficiaries in Cook County, Ill., “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.”

As such, the organization is 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 was used in combination with MHN ACO's patient demographics, social determinants of health (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, officials have stated.

"We want to identify what we refer to as the 'socially isolated' or people without nearby friends or family so our care teams can proactively educate and offer assistance to people in regards to COVID-19," said Art Jones, M.D., chief medical officer at Medical Home Network. 

Medical Home Network's ACO provides managed healthcare to approximately 120,000 Medicaid patients in Cook County. The ACO includes 10 federally qualified health centers (FQHCs), three hospital systems, and their physician practices.

Patients who have been identified as high risk for severe complications from COVID-19 infection will be contacted by MHN ACO care management teams who are employed by their primary care practices based in communities across Cook County and have built trusted relationships with patients, according to officials.

"Community preparedness is critical. The dedicated MHN care teams who proactively reach out to patients via phone, email or text will help individuals understand what they can do to lower their chance of infection, recognize symptoms of infection and how best to access the advice and care they need," said Jones.

Cheryl Lulias, president and CEO, Medical Home Network, added, "With limited availability for testing at present and the stress this pandemic will place on our healthcare system, we need ways to identify individuals that will most benefit from outreach. Medical Home Network is using our health risk data which includes social determinants of health powered by AI predictive models to prioritize resources in our communities. Our care teams can make a difference for those patients who are likely to have a heightened vulnerability to severe complications from COVID-19."