The COVID-19 pandemic has introduced multiple new threats for physical and mental health. The novel coronavirus itself continues to infect more than 30,000 Americans as we enter the influenza season. The pandemic, economic devastation, and racial reckoning have led to a tripling of emotional distress. Essential preventive services such as cancer screenings, childhood vaccination, maintenance visits for chronic illnesses have not recovered fully after plummeting in April; this will likely result in a surge of preventable illnesses and death in future.

In order to prevent these immediate and downstream effects of the pandemic—which the reactive American health care system is ill-equipped to address—we must invest in proactive patient outreach.

As physicians with decades of experience leading population health and proactive value-based care organizations combined between us, we outline below three aspects to consider when building a proactive patient outreach program for the COVID-19 era and beyond.

Identify patients with new vulnerabilities during COVID-19

Health care organizations have traditionally prioritized high-risk patients, who often have multiple serious medical conditions and frequent acute care needs. Yet, this reactive approach based on historical utilization patterns misses many patients facing new vulnerabilities posed by the pandemic.

During the COVID-19 epidemic, these “newly vulnerable” patients may include those with diabetes and hypertension working in an essential industry such as grocery or construction; those living in COVID-19 hotspots and of Black or Hispanic race; those who are elderly, living alone, and socially isolated; and those who are overdue for their cancer screening. 

Payors and providers should incorporate these new risk factors in their outreach prioritization. Population health insight tools, including those with advanced machine learning capabilities, can analyze clinical, demographic, and social determinants of health data to proactively and accurately identify such patients.

Focus on behavior change and social needs for impact

Helping patients minimize COVID-19 risk and socialize safely is of paramount importance, especially with pervasive misinformation and confusion on this issue. The first step is to assess for their correct understanding and current social practice patterns, such as physical distancing, hand washing, and mask use.  Then, health care organizations should engage these newly vulnerable patients to increase safe behaviors via text, phone calls, or in-person. Trust-building, evidence-based behavior change techniques such as motivational interviewing that link recommended behaviors, like wearing a mask, to a person’s goals should be utilized for maximal effectiveness, as recent news has reinforced a painful truth in health care: telling people what to do is rarely enough to change their behavior.

Outreach programs should also encourage and enable patients to receive non-urgent but essential care, such as cancer screening and chronic care management. This may include soothing their fears of going into a medical building, helping plan for safe transportation to and from their clinical visits, or assisting with a virtual visit setup when appropriate. 

Lastly, more patients are facing significant social challenges with health implications, such as unemployment, food or energy insecurities, or social isolation. Health care organizations should connect them to appropriate social agencies or help obtain necessary for living a healthy life services (e.g., free meal service for isolated seniors).

Leverage non-clinical staff to build trust and maximize return on investment

These outreach programs should hire and train non-clinical people, often referred to as patient advocates, health promoters, and community health workers. These health workers are generally from similar demographic and socioeconomic backgrounds as their patients and develop longitudinal relationships built on with mutual trust and shared lived experience.

Studies show that these workers can effect desirable health outcomes and provide a positive return on investment. Many recently, unemployed Americans or currently furloughed frontline staff could serve in this role for the benefit of patients.

One example of a successful proactive outreach program comes from the UNITE HERE HEALTH Fund for unionized casino, hotel, and restaurant union workers in Atlantic City. At the onset of the pandemic, the Fund’s health promoters reached out to its most vulnerable members and helped them manage their chronic conditions and stay safe from the virus despite the fear and hardship created by the pandemic. Health promoters also ensured that patients facing financial and health risks from COVID-19 had access to food, medications, and social services.

Payors should use record profits to incentivize providers and health systems to outreach patients proactively or build their own program. By doing so, we can avert many ill effects of this COVID-19 pandemic on patients and our fragile health care system.

Jason Bae is an internal medicine physician. Alan Glaseroff is a family physician.

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