Health Plans, COVID-19 Risk and Social Determinants | Geneia

Health Plans, COVID-19 Risk and Social Determinants

June 30, 2020
Heather Staples Lavoie, President and Chief Executive Officer


To better contend with COVID-19, health plan care managers need analytics and social determinant information.

Early research about COVID-19 has found that people with comorbidities like diabetes, hypertension and heart disease are at higher risk for COVID-19 complications and hospitalizations. Contemporaneously, 61 percent of patients report they have been adversely impacted by social determinants of health (SDoH) during the pandemic, a number most experts expect to rise as new unemployment claims top 40 million.

These realities put a premium on health plans using identification and stratification (ID and strat) that integrates social determinants and analytics revealing the members most likely to experience severe COVID-19 impacts.

Goal: Identify and Engage Health Plan Members at High Risk for COVID-19 Impacts

Geneia’s enhanced ID and stratification framework takes all that data, along with the progression model priorities set by the client, and systematically routes the cases to the appropriate queue – whether that is for direct member outreach by a nurse or coordinator, for email or text campaigns, or automated outbound call. The system smartly can match based on licensure, credentials, market – or other client specified criteria – and can do an automated push.

Let me show you how health plans can use Geneia’s enhanced ID and strat framework to better understand the needs of members, align the best intervention based on their health needs, perform outreach and run systematic engagement campaigns.

To identify and engage members at high risk for severe COVID-19 impacts, first, health plans use the COVID-19 predictive model created by the Geneia Data Intelligence Lab. Developed using risk factors reported in data from the United States and 20 countries in Europe, the model answers the question –

Given that a patient was to test positive, what is that person’s risk for developing severely adverse health outcomes, such as hospitalization?

The risk score allows identification of individuals at high risk for severe outcomes to guide appropriate allocation of care management resources.

Within Geneia’s data analytics platform, health plan care managers use the COVID-19 risk category filter to identify members at high, medium and low risk of severe impacts. The system further stratifies the population to focus on members who fall within the chronic and catastrophic risk tiers. Then, clinical markers aligned with the comorbidities that the Centers for Disease Control and Prevention (CDC) has outlined, e.g. obesity or diabetes with complications, are added. Typically, the focus is on clinical markers indicating pulmonary, heart or immunocompromised conditions.

To determine the prioritized patient pool, the system also adds in an age band of 55+ years old and members with an overall risk score of five or more. Geneia’s data analytics platform integrates social determinant information at the zip code-level, meaning health plans also able to identify populations of high-risk members in emerging COVID-19 hot spots as well as those most likely to use public transportation to commute to work or doctor’s visits. Care managers also routinely stratify members by open care gaps.

Goal: Identify COVID-19 high-risk members for clinical interventions and outreach

GOAL:

Identify COVID-19 high-risk members for clinical interventions and outreach

HOW:

  • Filter population by high, medium and low risk of COVID-19 severe impacts
  • Focus on chronic and catastrophic risk tiers
  • Add clinical markers, e.g. tobacco use or diabetes with complications, to further stratify population
  • Add age band of 55+ years old
  • Prioritize members with an overall risk score of greater than 5.0

Geneia’s enhanced ID and strat framework yields a sub-population that is ‘progressed forward’ to a care manager for outreach, care planning and coordination. The care manager can see them in their queue, with full detail on aging of the referral, the status, whether it has been started, in progress or complete.

For one health plan using the enhanced ID and strat framework, the population of 100,000 was narrowed to approximately 3,900 high-risk members for personalized outreach. Charles Green* is the kind of member found in the high-risk group.

Care management example screenshot

The health plan care manager selects Charles Green for outreach and the system pulls up an automated call script from a set of prepopulated scripts and leads the caller down a tree based on availability of the member. The care manager engages Charles, conversing with him about precautions he can take to better protect him from contracting COVID-19, conveying: “People with serious underlying medical conditions like chronic lung disease, heart conditions, and diabetes are at higher risk for severe illness from COVID-19. We want you to be aware of preparations to take.”

The care manager also talks with Charles about the importance of closing open quality opportunities related to his diabetes diagnosis. She can see in his patient record that he’s overdue for an HbA1C lab test. She works to schedule Charles for an appointment with special instructions for scheduling on a day for immunocompromised patients.

The social determinants of health tab reveals Charles may have transportation issues as the majority of people who live in his area commute without a personal vehicle. This information prompts the care manager to inquire about his ability to get to the doctor’s office. His answers, combined with plan design information that covers transportation costs, allows the care manager to arrange for transportation to ensure he is able to get to the office at the designated time, understand the precautions he must take, and close his open gaps. Similarly, if his needs could be addressed through telemedicine, the care manager could arrange for that and further reduce Charles’ potential exposure.

New population health standards from the NCQA require that engagement and interventions are performed for all levels of risk, not just for high risk members like Charles Green, but for the healthy and rising risk as well. There are not enough clinical personnel, or total health plan resources, available to manually or individually address the breadth of all member needs. That’s why we leverage journey management capabilities in Salesforce’s Health and Marketing Clouds to engage healthy and rising-risk members by email and text. Not only do the capabilities expand the outreach of health plans and improve engagement levels, the system captures the detailed statistics on outreach and engagement that NCQA and employers are increasingly seeking.

*Charles is fictional and not intended to represent any specific person. This information is provided for illustrative purposes only.


Related Blogs