IWC3 - Reply “CARE:” How Big Data Kept Our Patients Connected to Care During the COVID-19 Pandemic

A deadly pandemic. Business shut down and health center closure. Shelter in place. Financial stress. Racial Injustice. A Perilous Future.   In four months of outreach, 31,586 texts and phone calls were attempted to our elderly and chronic conditions patients, to check in and offer them telehealth appointments with their PCPs. We reached 32% (10,225) of them and successfully booked 5,320 mostly telehealth appointments. Highlights include 1,983 Diabetes and Hypertension patients reengaged in disease management and 756 seniors reconnected with their PCPs. As the burden of COVID infection, death and economic hardship among our patients of color became increasingly apparent, we expanded our efforts and made contact with 1,081 African-American and Hispanic/Latino patients and connected 681 (63%) of them with their PCP for a telehealth appointment. Understanding the mental health impacts of these difficult times, we completed a standardized depression assessment with 273 of our patients receiving a phone call. Overall, this outreach effort resulted in 3,947 billable visits and $480,000 in revenue.   Speakers will reflect on the financial benefits realized through this effort and clinical outcomes garnered, and share meaningful interactions between outreach staff and patients.