Medical Home Network ACO uses AI to identify safety net patients in Cook County at high risk for COVID-19

Medical Home Network’s Accountable Care Organization has partnered with ClosedLoop.ai to identify Medicaid patients who are most at risk for COVID-19.

The partnership combines a predictive model based on artificial intelligence with data collected by the Medical Home Network ACO, like patient demographics, social determinants of health, claims and clinical activity that was gathered during a health risk screening for new patients.

Of the roughly 120,000 Medicaid patients it oversees for Cook County Health, nearly 85 percent respond to the health risk screening, said Dr. Art Jones, chief medical officer at Medical Home Network. Of those, 368 patients said they were homeless, 5,5000 said they lived alone and nearly 10,000 said they had no friends, family members or others who could care for them if they became sick.

Jones said they used the predictive model to determine which of these patients have social risk factors and are most likely to have serious complications from COVID-19.

Those at risk will be contacted by the network’s care management teams to help them understand what they can do to lower their chance of infection, recognize symptoms of infection and how best to access the necessary advice and care.

Focusing outreach on at-risk individuals who are socially isolated is a lesson Jones said many in the city learned during the 1995 heat wave, which killed more than 700 people.

“People that were socially isolating and at risk as far as being vulnerable patients were often the ones who died (during the heat wave),” Jones said. “We’re taking a similar public health approach to COVID-19, as far as that goes.”

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