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Improving Population Health: Rapid Identification of Patients at Highest Risk of COVID-19

agilon health immediately understood the sizeable risk COVID-19 presented its members. The organization leveraged data and analytics to quickly develop a COVID-19 mortality risk model. agilon health distributed the risk data to its market partners for outreach, improving the ability of its partners to intervene to improve individual and population health.

Featured Outcomes

  • Deployed a COVID-19 risk model in just a few days, assigning risk scores to 125,000 members.
  • Within weeks, teams in each market connected with more than 50 percent of the patients at highest risk for COVID-19.
  • At one partner location, telehealth now comprises nearly 70 percent of visits. The partner went from zero telehealth visits in the first 11 weeks of 2020, to more than 2,200 telehealth visits in weeks 12 and 13.

Prioritizing Outreach for Care Coordination Amid the COVID-19 Pandemic

OneCare Vermont sought to identify which of its patients were at the highest risk of serious illness or mortality from COVID-19 and which of its patients with chronic healthcare problems needed care for medical issues other than COVID-19. Leveraging its data platform, OneCare Vermont enabled rapid identification of at-risk patients. Providers and care teams use the risk-stratification care coordination tool to proactively conduct patient outreach, including telephone calls and telemedicine virtual visits, ensuring patients receive needed social support and medical care during the pandemic.

Featured Outcomes

  • Just three weeks after the governor of Vermont declared a state of emergency, released a COVID-19 care coordination tool, applying the risk criteria to approximately 190K patients.
  • More than 500 cumulative sessions logged in the application across OneCare Vermont’s network.
  • Indicators of social complexity were included in the tool.

Integrated Data Platform Improves the Effectiveness of State-wide COVID-19 Surveillance

The Ohio Health Information Partnership (OHIP) was using its technology to share individual COVID-19 test results to providers at the bedside. The State Department of Health approached OHIP with a request to aid the state by providing a more comprehensive data set for COVID-19. Using the Health Catalyst® Data Operating System (DOS™) platform, OHIP has improved the effectiveness of public health reporting and COVID-19 surveillance.

Featured Outcomes

  • In just two weeks, implemented a COVID-19 reporting solution, enabling robust state-wide surveillance for public health purposes.
  • Dramatic reduction in the time required to implement robust public health reporting.
  • Integrated COVID-19 surveillance data and analytics for more than 150 hospitals and two large diagnostic companies.

Improving Population Health: Data-Driven Approach to Identifying and Engaging Patients with High Risk of Mortality from COVID-19

Leveraging the Health Catalyst® Data Operating System (DOS™) platform and the ACO Risk Stratification Dashboard, MemorialCare developed and implemented an algorithm to identify and risk-stratify members at the highest risk of mortality from COVID-19. Care managers can visualize at-risk members and the specific factors contributing to the increased risk, allowing them to quickly prioritize member lists for outreach—improving population health and decreasing mortality.

Featured Outcomes

  • Developed and deployed the algorithm for COVID-19 risk for mortality within four days. The algorithm was applied and visualized on MemorialCare’s entire ACO population.
  • Within one week, the algorithm was expanded to include MemorialCare’s entire HMO population.
  • 66 percent of individuals in the extremely high-risk category of MemorialCare’s ACO population were engaged by care management.

Population Health Strategies Improve Diabetes Management

Thibodaux Regional Health System recognized its patients with Type 2 diabetes had hemoglobin A1C (HbA1c) levels that exceeded the evidence-based guidelines for blood glucose control and sought to improve the health of this patient population. Using a data platform and a consistent improvement methodology, Thibodaux Regional learned more about the challenges to diabetes self-management in its population. The organization was then able to improve its outreach and support for patients with diabetes.

Featured Outcomes

  • 19.1 percent relative reduction of HbA1c for patients with diabetes in the first year of the organization’s improvement efforts.
  • 14.5 percent relative reduction of HbA1c for patients with diabetes in the second year of its improvement efforts.
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