Proactive Medical and Social Outreach for Atlanta’s Highest Risk Patients During COVID-19

In the wake of the COVID-19 pandemic, many patients are left without normal access to the healthcare they need. With necessary changes made to take on and protect others from COVID-19-- such as appointment cancelations, telemedicine visits, and pharmacy delivery-- thousands of patients at Grady Health System in Atlanta, Georgia who rely on regular health maintenance for their chronic and complex conditions now face an increased risk of complications. This initiative between Grady Health System and Emory School of Medicine in Atlanta, Georgia uses volunteer medical students to reach those at risk of poor outcomes now that they are encouraged not to leave home to seek care or fill prescriptions at the hospital.

Grady partnered with Jvion, a prescriptive analytics company, to develop a prioritized list of Grady’s 15,000 patients who are at highest risk of morbidity and mortality from COVID-19. Volunteer Emory medical students from the rising M3 and M4 classes use a new, tailored REDCap survey to conduct 15-20 minute standardized phone calls with patients on this list. During each call, students screen patients for COVID-19, check-in with patients about managing their chronic medical conditions at home, help patients safely obtain medications that they are out of, evaluate social needs, and refer patients to a myriad of COVID-specific and general resources to fill gaps. The organization of and content covered during each call was developed with substantial input from Grady Health System doctors and staff, who continue to serve as advisors for this initiative. Students review each patient's medical chart in Epic prior to calling and record a “patient outreach” encounter in their chart to document the discussion and alert members of the patient’s care team to any concerns -- whether routine or new. Volunteers are provided with a thorough Training Manual and a Patient Resources Guide to provide step-by-step guidance navigating any need a patient may have. The REDCap platform allows for collection and analysis of recurring patient social needs for future interventions. Graduating M4s are serving as “on call” resources should volunteer callers have clinical questions. The program will be expanded to include the Emory Physician’s Assistant students as well.