Connecting Care in a Pandemic: Data-Driven Outreach to At-Risk Populations

During the COVID-19 pandemic, patients avoided routine and even necessary care for fear of exposure to the virus. Reluctance to seek care creates complex challenges for providers and their patients. Using data, technology and value-driven care models, Southwestern Health Resources (SWHR) took immediate measures to reach out to at-risk members in North Texas and to maintain a connection to their physicians throughout the public health crisis.

The problem

During the second quarter of 2020, primary care providers saw a greater than 50% drop in volume, posing an increased risk to patients’ health, particularly for patients with chronic conditions. Elective surgeries declined, along with a drop in routine visits, creating a financial crisis across the continuum of care. Providers struggled to find balance between treating patients who tested positive for COVID-19 and safely maintaining continuity of care for all patients.

The opportunity

SWHR launched an immediate response to the pandemic to protect both patients and providers in their North Texas network. The speed and flexibility of their response demonstrated the inherent strengths of an integrated, data-driven approach to population health management and an infrastructure of support for physicians.

The solution

In March 2020, SWHR established a pandemic command center for operational and clinical leaders to coordinate the response. First up: direct support to community physicians to adopt and scale telehealth. Across the network, in-person visits were replaced with virtual visits nearly overnight. SWHR used data to identify and then reach out to at-risk patients, urging them not to delay care. It implemented remote monitoring for those with COVID-19 and employed value-based payment models to ease the financial challenges faced by community physicians — all within a few weeks.

The results

Telehealth practices were launched for approximately 400 community physicians in a single month; virtual visits rose from zero to approximately 8,000 per day. Nearly 1,000 vital “care-at-home” packages were sent to older adult patients. With an agile approach to population health management, supported by data, technology and an understanding of patient and physician needs, SWHR proved that care delivery can pivot to meet changing needs of both patients and providers — even during a pandemic.