LifeBridge Health

New Data-Driven Approach for Communities At Risk for Severe COVID-19 Outcomes

Newswise — Beginning this week, a statewide Taskforce on Vulnerable Populations for COVID-19 in Maryland began implementing a data-driven approach to identifying communities and individuals at highest risk for severe outcomes from COVID-19. They are using this data and mapping to guide the deployment of outreach and resources to vulnerable populations including homeless, elderly living in congregate dwellings and those with limited healthcare access.

The taskforce, led by Susan Mani, MD, LifeBridge Health’s Chief Population Health Officer, engaged a company called Socially Determined to leverage information from multiple data sources to generate a COVID-19 risk index for severe outcomes that was mapped on a county, city and neighborhood level throughout Maryland. (see attached examples of data and mapping – darker red areas had highest risk index).

 The risk score for communities and individuals and corresponding maps were shared with municipal health officials.  Those local health officials can take the data and mapping into account along with their local expertise to deploy their outreach, moving high risk groups into hotels for social distancing, testing, etc. 

Additionally, the Taskforce on Vulnerable Populations secured approval from Secretary of Health Robert R. Neall to create and deploy Testing and Manage in Place Teams comprised of EMS personnel and social workers/community health workers to institute measures designed to prevent negative COVID-19 outcomes to the most vulnerable communities. 

 As Testing and Manage in Place Teams are deployed, they are able to provide testing on site and also conduct brief clinical assessments to see if emergency telemedicine visits are needed since there are concerns that people may not be going to the hospital or their doctor’s offices even when they are sick out of fear of COVID. 

Teams are also assessing for social needs such as food availability, financial assistance, temporary housing needs and are connecting vulnerable populations with resources they need, including education about the disease to help them stay safe. 

By using this proactive approach, health officials can identify those at greatest risk of ending up in the hospital or ICU and try to prevent that from happening through early outreach testing and management. We know our vulnerable populations at greatest risk from COVID-19 and this kind of approach is being put in place to prevent negative outcomes as well as prevent the overwhelming EDs and hospitals.  

On a community level, Socially Determined took the following key factors into account when determining COVID-19 susceptibility on a community level:

- Age Distribution

- Community Disease Burden

- Population Density

- Economic Stress

- Exposure Potential

- Infrastructure

 On the individual level, Socially Determined took the following key factors into account:

- Age

- Chronic Disease History

- Social Determinants of Health Risk Data

Testing and Manage in Place Teams are working in communities right now and we can provide you with visuals or access to team members in action in vulnerable areas. We can also connect you with Dr. Mani, experts from Socially Determined as well as public health officials who are using the information to guide their efforts. We can show you what is being done and the impact it is having to reduce the spread of COVID-19 and reducing the burden on healthcare systems throughout the state.

 This is a unique approach to battling COVID-19 that could be adopted nationally. 


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