Prioritizing Outreach for Care Coordination Amid the COVID-19 Pandemic



Care coordinationOneCare Vermont sought to identify which of its patients were at the highest risk of serious illness or mortality from COVID-19, and desired to determine which of its patients with chronic healthcare problems needed care for medical issues other than COVID-19, or support to navigate the healthcare system and avoid risk. The participants’ EMRs did not have a mechanism to systematically identify patients with specific high-risk factors.


OneCare Vermont used the Health Catalyst® Data Operating System (DOS™) platform to leverage publicly available risk criteria, medical and pharmacy claims, medical data, and social factors data to identify high-risk patients, and to identify the patients at risk of a poor outcome if they were to get COVID-19. Providers can filter the risk criteria to prioritize patient outreach. Filters include options for narrowing selections to identify patients who:

  • Are over 60 years old with specific chronic conditions.
  • Are considered frail.
  • Are high users of healthcare resources.
  • Have seen at least seven different providers in the last year, indicating a potential care coordination issue.
  • Have evidence of mental health or substance abuse comorbidity.
  • Have high social complexity and challenges accessing food and/or social isolation.


Using DOS, 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.

  • 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.

“The care coordination prioritization application is enabling our teams to identify and proactively engage high-risk patients. Teams can provide much needed social support, and can ensure patients receive needed medical care.”

– Tyler Gauthier, MHA, CPHQ, CSM, Director, Value-Based Care


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