AllWays Health Partners’ Population Health Response to COVID-19

Massachusetts has been one of the states hit hardest by the COVID-19 pandemic. Below are some ways that the AllWays Health Partners Population Health and Analytical teams have responded to assist our population. This includes developing specialized outreach programs and expanding or transforming existing services.

If any of these offerings would be beneficial for your patients, please send an email to the following address to discuss coordinating care for your patient: caremanagement@allwayshealth.org

Creation of new outreach initiatives

Using the CDC guidelines to inform who would be most impacted by the pandemic, we identified individuals within our population and categorized them so our Population Health teams could perform specialized outreach to determine if they needed additional assistance during this time. The categories used include:

• Pregnancies in 3^rd trimester
• High risk based on age
• ED visits for suspected COVID-19
• COVID-19 positive diagnosis
• Chronic condition patients who may be deferring care

Education and resources provided during our interactions with patients

COVID-19 has prompted new information and education to be incorporated into the interactions the AllWays Health Partners Population Health Teams have with patients, including:

• General COVID-19 education, including the importance of social distancing, ways to clean your home to minimize contagion, and how to isolate within a shared home if someone is suspected or has COVID-19 as well as reinforcing isolation guidelines given by patient’s health care providers
• Importance of a health care proxy (regardless of age)
• Ensuring all social supports are in place and evaluating social determinants of health
• When appropriate, our Pop Health Teams can assist patients using our knowledge of Social Support Resources such as:
  • COVID-19 specific government aid and other aid options
  • Childcare
  • Food resources
  • Government social services
  • Housing resources
  • Senior care
  • Unemployment services
  • Utility assistance options
  • Legal resources
  • Domestic violence resources (elder abuse/neglect)

Specialized offerings in response to COVID-19

The pandemic has caused some unique biopsychosocial issues to arise within our world. Our Pop Health Teams have been able to leverage and adapt existing resources and technologies to address these issues within our population:

• Virtual care management: Parts of our Population Health Care Management team are now leveraging the same platform used for our Provider Network to perform virtual visits with members who have chronic conditions
• Expansion of transportation assistance: Now that public transportation is no longer an option for people and could pose additional risk for members, we’ve been able to expand transportation assistance for those who may be in need
• Community Servings: Meal assistance program for those with chronic conditions who may have difficulty getting food during this time
• Behavioral health offerings: Services for mental health support in managing stress, anxiety, and depression, such as Live and Work Well and the Sanvello app, for which AllWays Health Partners members can get a free premium upgrade for 12 months by subscribing with their insurance info

Continuation of existing programs

Many of the Population Health programs already in existence within our organization have been able to assist in COVID-related efforts and have also been able to continue performing their pre-COVID work:

• Tobacco Cessation Education and Coaching
• Health Coaches
• Mother & Child Health – Pediatric Program
• Disease Management (Respiratory, Cardiac, Diabetes)
• Complex Care Management
• Your Care Circle