Telephone Outreach Serves Vulnerable Patients in Need
Many medically vulnerable patients in Einstein Healthcare Network’s primary care practices received an unexpected phone call during the height of the COVID crisis. They’d been identified as highly susceptible to having severe complications if they contracted the virus, and Einstein called to check up on them.
One 93-year-old patient was “so overjoyed and grateful for the conversation that she could not stop giggling,” an outreach worker says. “I was the first person she had spoken to in days.”
More than 3,000 patients were connected to resources to have their prescriptions and their empty cupboards filled, were provided information about COVID, had telehealth appointments arranged with their primary care physicians, and more.
Beyond Medical Care
One patient who had no food was signed up for food stamps. Another was coached to stop smoking. A third who was unable to pay her rent was referred to a tenant advocacy program.
“People were incredibly appreciative of the information, of hearing someone else’s voice,” says Emelia Pine, manager of the Complex Care Management Program (CCMP) of Einstein Care Partners.
The calls were an outgrowth of intense monitoring regularly provided to an average caseload of 30 patients by CCM. Through this program, community health workers and social workers visit patients once, twice or multiple times a week to make sure they’re stable.
“These patients have uncontrolled chronic health conditions such as diabetes, heart failure, hypertension, chronic kidney disease,” Pine says. “They have food insecurity, or their housing is at risk, or they experience domestic violence. They can’t afford co-pays on their medication and have difficulty accessing healthcare.
“The goal is to identify and support the patient and reduce the barriers to health and social needs,” she says.
Calls to All Vulnerable Patients
When COVID struck, in-person visits became impossible. And a decision was made to expand the telephone outreach from the small caseload to all patients treated by Einstein Care Partners (ECP) who were considered exceptionally vulnerable to having severe complications or death if they contracted COVID. ECP is Einstein’s Accountable Care Organization that is focused on quality of care for about 50,000 patients in Philadelphia, Elkins Park and Montgomery County.
Patients were ranked based on a “COVID vulnerability score” and outreach began in mid-March. By the end of June, a total of 4,000 calls were made to more than 3,000 patients in Philadelphia and Elkins Park. As the crisis escalated, primary care nurses joined in making calls.
A similar project contacted patients linked with Einstein Medical Center Montgomery.
“The biggest needs the team identified were running out of medication and, for patients who were homebound or socially isolated, not being able to get food in the home,” Pine says.
The outreach workers were able to identify community resources who were delivering food to homebound neighbors. They also had direct access to primary care physicians to refill prescriptions and make sure the medications were made available.
If a patient had COVID symptoms, the team arranged a follow-up call with a physician for evaluation. The number of patients who tested positive for the virus was not tracked.
“Many high-risk patients are very isolated and may not have high levels of support,” Pine says. “They appreciated that someone from Einstein was looking out for them.”