Advocacy in Action: a Comprehensive Student-Led Proactive Outreach to Patients at Highest Risk.

Area of Science:

• Health Systems Science
• Public Health
• Telehealth

Background:

• COVID-19 significantly disrupted healthcare access, particularly for patients at safety-net hospitals managing complex conditions.
• Patients relying on regular care faced challenges in accessing critical resources and maintaining treatment continuity.

Purpose of the Study:

• To proactively identify and address the clinical and social needs of high-risk patients in Atlanta, Georgia, who lost usual healthcare access.
• To implement a telephonic outreach program to bridge care gaps and support vulnerable patient populations.

Main Methods:

• Medical and Physician's Assistant students partnered with Grady Health System, Atlanta's safety-net hospital.
• Artificial intelligence identified over 15,000 high-risk patients. Students conducted telephonic outreach using a custom REDCap form for screening, education, and resource connection.
• The REDCap form guided students to assess COVID-19 risk, navigate health system changes, and identify social determinants of health.

Main Results:

• In 16 months, 7,988 calls were made, with 3,354 answered.
• Over half (53%) of patients contacted had at least one need requiring intervention, including 48% with health needs and 16% with social needs.
• The program successfully identified substantial unmet clinical and social needs.

Conclusions:

• This novel initiative effectively addressed critical health system gaps exacerbated by the COVID-19 pandemic.
• The program demonstrated a rapid, cost-effective method for high-yield patient outreach to promote home-based health.
• It serves as a scalable model for supporting patient health during and beyond public health crises.