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Helping High-Risk Patients Stay Healthy at Home During COVID-19: A Comprehensive Student-Led Clinical and Social Outreach

Authors

1-Rebecca Goldstein, MPH; 1-Alyssa Greenhouse, BA; 1-Anjali Om, BA; 2-Georges Bouobda Tsemo, BS; 3-Leslie Marshburn, MBA, MPH; 4-Maura George, MD; Affiliations: 1- Emory University School of Medicine, Atlanta, GA 2- Morehouse School of Medicine, Atlanta, GA 3- Grady Health System, Atlanta, GA 4- Emory University Department of General Medicine, Atlanta, GA

Introduction

During the COVID-19 pandemic, many patients lack access to the critical healthcare and resources they need. The healthcare gap worsened by COVID-19 is especially pressing for patients Grady Health System, Atlanta's safety net hospital, who rely on regular care for multiple complex comorbidities. As health professional students were removed from clinical rotations, we identified a gap in patient care: from the sidelines, we could support high-risk patients by helping them to navigate the abrupt changes to the healthcare system and proactively addressing health concerns at home. A collaboration between Emory and Morehouse Schools of Medicine and Grady Health System uses 300 volunteer health professional graduate students (MD and PA) for telephonic outreach to thousands at highest risk of poor outcomes if they were to contract COVID-19. We comprehensively 1) screen patients for COVID-19 and educate on prevention; 2) help patients navigate healthcare system changes during the pandemic and fill gaps in their care; and 3) identify and address patients' social needs by connecting them to appropriate resources.

Methods

Fifteen-thousand patients were identified through an artificial intelligence program and prioritized by risk of morbidity and mortality from COVID-19. Students call patients in order of risk. Students designed a novel REDCap form to serve both as a script to facilitate conversations with patients and as a data collection tool to track patient needs. The form provides step-by-step guidance to screen the patient for COVID-19 symptoms, general health, medications or medical supply needs, and social impacts and support needs. Based on a patient's responses, the REDCap form systematically prompts callers to provide important health reminders, and produces referrals tailored to the patient's needs. Referrals are for health resources (e.g. medications, mental health, and appointments), as well as social resources (e.g. food banks, housing, and rent/utility assistance). Students can conduct three-way calls for additional support, including to the Georgia Crisis and Access Line for acute mental health crises and to the hospital's Nurse Advice Line for urgent health crises at home. Students document the discussion in the medical record and alert the patient's care team with any concerns.

Results

To date, students have made 4,435 calls and 1,772 have been answered. Strikingly, almost half of the patients (47%) required connection to a clinical or social resource: 41% to a medical referral, 27% to medications refills, and 15% to a social referral.

Conclusion

This interdisciplinary initiative leverages students and technology to fill a pressing and new health system gap as a result of COVID-19. These proactive outreach calls have become a required part of the curricula at both medical schools. Early results indicate that this program has filled a clear gap, and an investment from our health system to continue proactive services like this throughout the COVID-19 pandemic and likely during conventional times is paramount.

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Back to the January 2022 issue of ACP IMpact