A few months into the pandemic Natalie Curtis, MD, Primary Care and the Ambulatory team noticed fewer patients were coming in for routine health care services. “As a result, they were at risk of not getting their health care needs met,” said Curtis. That’s when Curtis and the Ambulatory medical staff volunteered for a patient outreach pilot targeting patients assigned to Alameda Health System (AHS).
Working from a list of patients due or overdue for visits and at high risk of hospitalization, providers and medical staff called patients and assisted them with setting up appointments. They discovered many patients didn’t realize AHS hospitals and clinics were open for services during COVID-19 or that telemedicine was an option for them.
What began with the goal of contacting patients to get them back on track for regular visits with their primary care providers turned into a unique broader mission to connect patients to community services by asking one simple but impactful question, “How can we help you?”
The Alameda Hospital Complex Care team called 73 patients identified as high-risk by the Alameda Alliance for Health and were able to connect and set up appointments for 48 patients. When asked what else they needed, patients identified their top three requests as help making appointments, behavioral and mental health referrals, and community food resources. Patients were then given community contacts to support their critical and immediate needs.
In Primary Care, 178 patients were called and over 50 percent were successfully scheduled for appointments. Food, housing and mental health resources were identified as their top three immediate needs.
Curtis shares that patients were incredibly thankful for the phone calls to assist with appointments and information about local resources.
“Efforts to improve health have traditionally looked to the health care system as the key driver of health and health outcomes,” says Curtis. “Through our outreach, we began to look at ambulatory care through a new lens, one that takes a closer look at the social determinants of health for our patients outside the walls of AHS.”
Social determinants that support healthy environments include access to good schools, available jobs, affordable housing and food, and reliable transportation. Together they create the foundation for healthy communities where people can thrive. Without them, the health equity gap widens as seen by the patients and community AHS serves.
The AHS work continues supporting patients and connecting them to community resources. A new inreach effort started last month for patients seen in Urgent Care who are identified as a Person Under Investigation (PUI) for COVID-19 and who may need help to self-isolate. They are immediately connected with support services if needed.
“A critical takeaway from our patient outreach effort continues to be a heightened awareness that health related social needs in our community are intrinsically linked to the health care we provide our patients every day,” says Curtis.
For more information and resources:
- For information on COVID-19 and local community resources visit the AHS website
- For information on access to healthy food during COVID-19 visit the Alameda County Foodbank website
- For information on available housing during COVID-19 visit Homeless Solutions in Alameda County
- Learn more about social determinants of health on the CDC website