Strategies for Prioritizing Outreach to Prevent COVID-19 Related Hospitalizations

Last updated April 17, 2020 4:06 p.m. ET

With the risk of COVID-19 overwhelming hospital systems, many healthcare organizations are considering how best to use their existing resources (primary care providers, advanced practitioners, nurses, care managers, etc.) to help prevent COVID-19 related hospital admissions. Having worked with several organizations on outreach prioritization strategies, we thought it might be useful to share our recommendations.

Preventing admissions and preventing admissions from COVID-19 are not the same goal. Rather than rely on risk scores or more sophisticated machine learning-based approaches, we suggest a hierarchy of triage strategies informed by available evidence and supported by simple queries.

The strategies below are listed in order of suggested priority. For each strategy listed, prioritize outreach to individuals in descending order by age.

1. Prioritize outreach to patients with suspected, presumed, or confirmed COVID-19 infections.

Follow up with presumed or positive COVID-19 cases to assess which can recover safely at home versus which may require hospitalization. Organizations should track this list closely to ensure trained clinicians follow up routinely to mitigate community spread.

People with COVID-19 can experience a range of symptoms. It will be important for teams to have clear guidelines for triaging patients. For example, positive but asymptomatic may be a follow up call weekly or every three days. Shortness of breath or chest pain, on the other hand may require more immediate medical attention.

2. If possible, create a list of patients in nursing homes or long-term care facilities.

This information will be available to payers, and may be available to healthcare providers that have financial risk-sharing arrangements with payers (e.g., Medicare Advantage plans, NextGen ACOs) or organizations that represent both the payer and provider (e.g., duals plans, PACE programs). Organizations without access to such data can proactively reach out to local facilities to assess the needs of patients and deploy resources accordingly.

3. Prioritize patients whose needs were previously met with scheduled clinical interactions.

Among patients with chronic, complex diseases are a subpopulation whose health is dependent on routine interaction with the healthcare system. These individuals can be identified in data using queries on usage of durable medical equipment, care management interactions, specific medications, assignment to home care agencies, meal and / or medication delivery, transportation, routine in-person medical services, etc.

As key examples: any patient on home oxygen should be followed up with. This information should be available in the durable medical equipment (DME) files. Although more difficult to ascertain from the data, any patient over 65 known to be living alone should be outreached to (consider looking for no listed significant other).

Not coincidentally, they are likely to have several conditions that put them at risk for hospitalization if infected. Most critically, their existing medical needs, if unmet, increase their odds of exposure. As with the previous tiers, this population is likely to be small enough and with enough acute medical need to warrant proactive outreach by clinicians (nurses, PCPs, etc.)

4. For the remaining majority, do not over-invest in precision.

The majority of patients over the age of 65 will have one or more comorbidity and therefore fall into this high risk category. The number at risk is so high that we recommend teams complement prioritization strategies with ways to get in touch with as many people in this group as possible. In other words, while sophisticated prediction can be helpful for finding needles in the haystack, in this population there may be more needles than hay.

For these reasons and the high risk posed to everyone 65 or older, we suggest writing simple queries that take into consideration age and the following factors:

CDC-published drivers of severe COVID-19 disease (for those age 65+). The conditions identified thus far by the CDC with a higher risk of severe illness from COVID-19, that can be identified via ICD-10 or problem list query, include: chronic lung disease, heart disease, liver disease, chronic kidney disease, diabetes, HIV/AIDS, asthma, and cancer.

Obesity (BMI over 40) and history of smoking are correlates of severe disease that may be identified within the electronic medical record. Though again, with so many at risk, the benefit of prioritizing by EMR-based factors may be outweighed by the cost depending on how each institution’s data is structured and how accessible it is.

Procedures. Examples of procedures that can be identified via common procedural terminology (CPT) codes that are correlated with severe disease from COVID-19 include dialysis, bone marrow or organ transplantation.

Zip code. Population density and lower socioeconomic status are correlated with disease spread and severity. Certain zip codes can be prioritized accordingly.

Closing Thoughts

We are incredibly grateful to all who put themselves in harm’s way to care for those most in need and appreciate the opportunity to contribute in any way possible. We will continue to update this document as we learn. Please do not hesitate to contact any of us to ask questions or discuss ideas.

Caitlin Brennan, PhD, NP

VP of Clinical Improvement, Cyft Inc.

Visiting Scholar, Boston College

cbrennan@cyft.com

Adin Shniffer, MBA, MSc

Engagement Manager, Cyft Inc.

ashniffer@cyft.com

Leonard D’Avolio, PhD

CEO, Cyft Inc.

Asst. Professor, Harvard Medical School and Brigham and Women’s Hospital

ldavolio@cyft.com