Overview

Oak Street Health, a network of 56 value-based primary care centers serving nearly 80,000 adults on Medicare, developed a remote care program allowing them to conduct 93% of visits using telehealth, provide COVID-19 specific support, address social determinants of health through wellness checks and supply deliveries, and implement safety protocols for those providing in-person care.

Organization Name

Oak Street Health

Organization Type

• Community health system
• Community outpatient clinic
• Startup primary care practice

Tech Involved

• Electronic medical record
• Telemedicine software
• Telephone
• Video conferencing

Team Members Involved

• MAs
• NPs
• PAs
• Physicians
• RNs

Workflow Steps

• Telehealth Program: Software capabilities were added to existing platforms and all possible patient interactions were transitioned out of centers.
  • In-person visits were permitted by exception, evaluated on a defined set of clinical criteria (e.g. cognitive impairment, communication barriers, or need of an in-center test or procedure). As many staff as possible were moved out of centers to working from home under a new shift-based remote staffing model.
  • Telehealth visits were designed to mimic in-person visits by using a team-based approach to care. 
    • A medical assistant virtually checks vital signs, performs structured assessments using Canopy software, and notes changes or refills to medication as needed.
    • A provider (physician, NP, or PA) completes the remote visit with the help of a scribe, who manages patient data using a population health and preventive screening dashboard.
    • To enable remote monitoring, items like digital thermometers or simple pulse oximeters were mailed to patients who needed them.
  • Patients were taught to install and use Canopy software on their personal devices. 
• COVID-Specific Resources: A rigorous model was established for COVID-19 positive patients including hospital stay, remote monitoring, daily rounding, and evidence-based guidelines for supportive care. 
  • A registry of all suspected and confirmed cases was created, and care team members then used standardized acuity levels to determine which interventions were needed (e.g. nursing calls, food delivery, or access to social work services). 
  • COVID-19 testing was provided for rare in-person visits and a COVID-19 hotline was staffed by clinicians to address virus-related patient concerns. 
• Social Determinants Support (SDH): Outreach callers analyzed “patients’ physical, mental, and emotional health needs and screen for adverse SDH.”
  • Drivers and vans that were previously used to transport patients were turned into a delivery fleet for medical supplies.
• Protecting In-Center Staff/Patients: Quality Improvement and Population Health teams mobilized local staff to count and test all PPE daily and record this information in a centralized online location. 
  • In each center, patient flow was choreographed from the parking lot through a visit to limit exposure, with staff rotating in teams through centers to avoid cross-contamination in case of an exposure. Nearby centers were combined into a single practice when demand and supply of visits was lower.
• Leadership Response: A cross-collaborative COVID Response Team was established to track spread and provide clinical intelligence to the Oak Street Health response plan, along with established Executive, Clinical, and Operating Teams to provide overarching structure to operations. 
  • An internal and external communications strategy was further put in place to provide transparent and frequent updates to patients, staff, and partners.

Outcomes

• 93% of Oak Street Health’s 2,200 daily patient visits are remote through phone or video. 
  • Up to 25% of virtual visits on a given day are done by video; the rest are conducted by phone. 
• At the height of the intervention, more than 5,000 daily wellness checks were performed to ensure patients were stable and safe at home. Fewer are needed now. 
• Fewer COVID-19 cases were seen than anticipated.

Unique Challenges

• Low-income patients have no or little access to home Wi-Fi or devices to use the telehealth platform. Oak Health anticipates that only 50% or less of their patients can be served via video-visits.

Sources

• Myers G, Price G, Pykosz M. A Report from the Covid front lines of value-based primary care. NEJM Catalyst 2020. https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0148.