Proactive Outreach for At-risk Health Plan Members During COVID-19 Pandemic in New Mexico.

OBJECTIVE: -Explore the impact of proactive outreach to a health plan population during COVID-19 pandemic in New Mexico. BACKGROUND: -By March 2020, the 2019 novel coronavirus (COVID-19) was a global pandemic, circulating in more than 114 countries. As more information about virus transmission, symptoms, and comorbidities were reported over time, recommendations for reducing the spread of the virus within communities was provided by leading health organizations like the Centers for Disease Control and Prevention (CDC). METHODS: -Criteria were developed to identify health plan members most at risk for virus complications. Once members were identified, a health plan representative contacted each member to inquire about member needs, questions, and provide them with resources. Members were then tracked for COVID-19 testing results and vaccination status. RESULTS: -Overall, 50,000+ members received an outreach call (during 8-month timeframe), and 26,000 calls were tracked for member outcomes. Over 50% of the outreach calls were answered by the health plan member. Of the members who were called, 1186 (4.4%) tested positive for COVID-19. Health plan members that could not be reached represented 55% of the positive cases. A chi-square test of the two populations (reached vs unable to reach) showed a significant difference in COVID-19 positive test results (N = 26,663, X2(1) = 16.33, P<0.01). CONCLUSIONS: -Community outreach was related to lower rates of COVID-19. Community connection is important, especially in tumultuous times, and proactive outreach to the community provides an opportunity for information sharing and community bonding.

Is Mental Illness a Risk Factor for Hospital Readmission?

People with mental illnesses (MI) receive suboptimal care for medical comorbidities and their high risk for readmission may be addressed by adequate medication management and follow-up care. We examined the association between MI, medication changes, and post-discharge outpatient visits with 30-day readmission in 40,048 Medicare beneficiaries hospitalized for acute myocardial infarction, heart failure or pneumonia. Beneficiaries with MI were more likely to be readmitted than those without MI (14 vs. 11%). Probability of readmission was 13 and 12% when medications were dropped or added, respectively, versus 11% when no change was made. Probability of readmission also increased with outpatient visits.

The Development and Implementation of an Electronic Health Record Tool for Monitoring Metabolic Syndrome Indices in Patients with Serious Mental Illness.

OBJECTIVES: 1. A quality performance improvement (QI) project to implement an electronic screening and monitoring tool to record components of the metabolic syndrome (e-MSD) during clinic visits by persons with serious mental illness (SMI). 2. To encourage psychiatrists to use this tool in their documentation. METHODS: Working with the information technology staff, five psychiatrists developed, tested, revised and embedded the e-MSD tool into the medication management document within the electronic health record. A continuing medical education program on metabolic syndrome was developed and released to psychiatrists and mental health clinicians. Psychiatrist offices at one clinic were equipped with weighing scales, sphygmomanometers, waist circumference tapes, and a QI project was initiated. RESULTS: At one month, 9 to 12% of the anthropometric measures (height, weight, body mass index, waist circumference, and blood pressure) were recorded in 974 unique patient encounters, and one year later the numbers moved upward from 15 to 41%. Toward the end of Year 1, a Patient Care Associate was hired to measure the anthropometric measures and, one year later, the documented rates increased to 75-80%. Laboratory recordings (glucose and lipids) remained ≤8% throughout the first year, but moved upward to 25% in Year 2. DISCUSSION: Notwithstanding significant administrative and technical support for this QI project, changing clinician practice to screen, monitor and document metabolic indices in persons with SMI in the ambulatory setting changed significantly after the hiring of a Patient Care Associate. Efforts to obtain laboratory measures in real time remain a challenge. Next steps include interventions to promote weight loss and smoking cessation in SMI patients, and effective communication with their primary care doctors.

The Development and Implementation of an Electronic Health Record Tool for Monitoring Metabolic Syndrome Indices in Patients with Serious Mental Illness.

Objectives1. A quality performance improvement (QI) project to implement an electronic screening and monitoring tool to record components of the metabolic syndrome (e-MSD) during clinic visits by persons with serious mental illness (SMI). 2. To encourage psychiatrists to use this tool in their documentation.MethodsWorking with the information technology staff; five psychiatrists developed, tested, revised and embedded the e-MSD tool into the medication management document within the electronic health record. A continuing medical education program on metabolic syndrome was developed, and released to psychiatrists and mental health clinicians. Psychiatrist offices at one clinic were equipped with weighing scales, sphygmomanometers, waist circumference tapes and a QI project was initiated.ResultsAt one month, 9 to 12% of the anthropometric measures (height, weight, body mass index, waist circumference, and blood pressure) were recorded in 974 unique patient encounters, and 1 year later the numbers moved upwards - 15 to 41%. Towards the end of Year 1, a patient care associate was hired to measure the anthropometric measures, and one year later, the documented rates increased to 75-80%. Laboratory recordings (glucose and lipids) remained ≤ 8% throughout the first year, but moved upwards to 25% in Year 2.DiscussionNotwithstanding significant administrative and technical support for this QI project, changing clinician practice to screen, monitor and document metabolic indices in persons with SMI in the ambulatory setting changed significantly after the hiring of a patient care associate. Efforts to obtain laboratory measures in real-time remain a challenge. Next steps include interventions to promote weight loss and smoking cessation in SMI patients, and effective communication with their primary care doctors.