There is at least one organization, Medical Home Network, an organization serving 122,000 patients in the Cook County Chicago area, who used risk adjustment and predictive analytics to identify individuals who have an increased risk for severe complications from COVID-19. Cook County happens to be the most populous county in Illinois as well as the second most populated county in the country.
This initiative helped the organization conduct important patient outreach to drive coronavirus testing. Patients who were identified as high risk for severe complications from COVID-19 were contacted by care management teams that already had built trusted relationships with these patients. Community preparedness was vital.
Using AI and factoring in conditions like social determinants of health, they are able to identify patients at risk of admission, minimize ED visits with direct interaction with a care manager, and prepare resources such a bed capacity, staffing , testing , etc. They were also able to use social determinants of health to identify individuals who lived alone or did not have access to resources like housing since this section of the population would be at extreme risk. So instead of reaching out to all 122,000 patients, they were able to concentrate initial outreach to 4.4.% of the patients who were at particular risk. Telehealth rules have been relaxed and companies have gone so far as to provide at risk members with iPads for interaction with their physicians or care management teams.