Number of organizations using the COVID-19 Care Coordination Prioritization application as of 4/28/2020
The OneCare COVID-19 application now includes social determinants of health data, specifically social isolation and food access, to help providers identify patients with the greatest risk of COVID-19. The social determinants of health criteria is in addition to previously identified risk factors which include age greater than 60 with chronic conditions, frailty score, potential for fragmented care, mental health or substance use conditions, and high healthcare resource usage. Criteria used in the app was developed by the World Health Organization, Centers for Disease Control, and Johns Hopkins.
The goal of the application is to help providers outreach to patients with the greatest risk in order to keep patients safe and out of the hospital. Providers can work with patients to develop emergency plans, help them with prescription needs, identify social needs, and help to support their management of their chronic conditions.
To date, thirty organizations in the OneCare network have used the COVID-19 Care Coordination Prioritization application to identify patients with the greatest COVID-19 virus risk.
The app is available in WorkbenchOne. If your organization does not yet have WorkbenchOne access, OneCare staff can provide exported lists of the patients with the greatest risk in HIPAA-compliant format such as secure email.
Please contact OneCare’s Analytics team at Data@onecarevt.org with any questions about the application.
December 2020 Update:
The application has been profiled by several prominent local and national organizations:
- Center for Health Care Strategies https://www.chcs.org/resource/connecting-with-high-risk-patients-when-in-person-visits-are-not-possible
- Health Catalyst Success Stories Line-up: https://www.healthcatalyst.com/success_stories/care-coordination-during-covid19-onecare-vermont
- Policy in Plainer English http://www.plainerenglish.org/866545/3628789-telehealth-and-the-telephone-epilogue-ccm
- Webinar about population health approaches to care for patients with complex needs amid #COVID19from Center for Health Care Strategies: https://www.chcs.org/resource/engaging-patients-with-complex-needs-amid-covid-19-lessons-from-provider-organizations
- Featured at Health Analytics Summit 2020: https://www.onecarevt.org/has-2020