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


risk model


agilon health immediately understood the sizeable risk COVID-19 presented its members. It desired to create a risk model to identify the patients with the most considerable risk for mortality, providing primary providers the opportunity to connect with their patients in new ways to improve population health.


agilon health leveraged the Health Catalyst® Data Operating System (DOS™) platform and its Patient-Level Data Mart (PLDM) to develop a COVID-19 mortality risk model quickly. Risk factors for COVID-19 severity rates were gathered from U.S., China, and Italy research studies and sources, and are weighted according to mortality rates. Risk factors include age, co-morbidities, institutionalized stats, and social determinants like living in high-poverty and high population density areas. Every patient is assigned a weighted score according to their unique combination of risk factors.

agilon health distributed the risk data to its market partners for outreach. Teams in each market contact high-risk patients, encouraging social distancing, the precautions that could be taken to minimize the risk of becoming infected, and the need to shift to telehealth appointments as a mechanism for staying connected to their primary care provider to maintain health.


agilon health leveraged DOS and PLDM to quickly respond to an emerging issue, improving the ability of its partners to intervene to improve individual and population health.

  • 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.

“Using DOS and the Patient-Level Data Mart, we were able to quickly identify patients at high risk of COVID-19, enabling our partners to perform targeted outreach to improve population health.”

– Lauren Polt, MA, Director of Clinical & Quality Analytics, agilon health

“The flexibility of the data platform supported our teams in rapidly responding to emerging COVID-19, integrating data into the data platform to improve patient outreach.”

– Lee Parks, MBA, Vice President of Data Solutions, agilon health


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