The COVID-19 pandemic is catalyzing approaches to care that ensure people with complex health and social needs receive services when they need them most. Some innovative health care providers are adopting population health management strategies to proactively identify and connect with individuals at higher risk of severe illness from contracting COVID-19 or people with chronic conditions who are unable to access care.

In this webinar, made possible through support from the Robert Wood Johnson Foundation, three provider organizations detailed how they are using population health management approaches — such as risk stratification tools that incorporate social factors and new patient engagement and screening approaches — to care for people with complex needs amid COVID-19. Speakers described their innovations, challenges, and lessons to inform organizations interested in adopting person-centered, proactive approaches to care.


I. Welcome and Introductions

Speakers: Karla Silverman, MS, RN, CNM, Associate Director, Complex Care Delivery, CHCS; and Susan Mende, BSN, MPH , Senior Program Officer, Robert Wood Johnson Foundation

K. Silverman welcomed participants and discussed the value of population health management approaches during and after COVID-19. S. Mende highlighted the Robert Wood Johnson Foundation’s commitment to supporting care models that better integrate services for people with complex health and social needs.

II. OneCare Vermont: Using Data to Identify High-Risk Patients

Speaker: Tyler Gauthier, MHA, CPHQ, CSM, Director, Value-Based Care, OneCare Vermont

T. Gauthier discussed a new care coordination tool that allows providers to quickly identify patients most at risk for serious illness or mortality related to COVID-19 can help them to assess and address care needs of patients.

III. Montefiore Medical Group: Redesigning Screening During the COVID-19 Crisis

Speakers: Miguelina Germán, PhD, Director, Pediatric Behavioral Health Services, Montefiore Medical Group and Teresa Hsu-Walklet, PhD, Attending Psychologist, Behavioral Health Integration Program, Children’s Hospital at Montefiore Health System, Bronx, New York

M. Germán and T. Hsu-Walklet highlighted how their team redesigned their Pediatric Behavioral Health Integration Program to address the COVID-19 surge in the Bronx, which included a new triage process that broke down silos between the pediatric and adult treatment programs and assessed activities of daily living, health-related social needs, self-harm, and other stressors for the entire family.

IV. Maimonides Medical Center: Engaging Patients through Text Messaging

Speakers: Danielle Cuyuch, MUP; Senior Director, Population Health Program Integration and Magdalena Gordon, LMSW, Director, Behavioral Health Care Management Maimonides Medical Center, Brooklyn, New York

D. Cuyuch and M. Gordon described the health center’s adoption of text messaging for patients receiving care management to check-in on medical and health-related social needs and provide connections to relevant providers and community-based organizations.

V. Moderated Q&A

Moderator: Karla Silverman, CHCS