As part of its efforts to help support the health needs of the Rhode Island community during the COVID-19 pandemic, the data and analytics team at Blue Cross & Blue Shield of Rhode Island (BCBSRI) has launched a COVID-19 public health dashboard. The dashboard calculates a COVID-19 risk score for each BCBSRI member in an effort to better inform providers and BCBSRI care managers of patients most at risk for COVID-19.

To identify the population most at risk from COVID-19, BCBSRI created a scale that runs from 0 (least risk) to 10 (most risk) and is based on the Centers for Disease Control and Prevention (CDC) highlighted risk factors. The risk score is then calculated on a number of factors, such as age, type 2 diabetes diagnosis, pulmonary issues or asthma, heart conditions or admissions to skilled nursing facilities.

“The BCBSRI risk score is unique in that it is able to leverage a broad base of factors based on a combination of data, including 12 months of claims, social vulnerability index, hospital admissions and discharges, public health data such as coronavirus cases recorded by the Rhode Island Department of Health and other private data sources. The result: a data-driven, targeted response to COVID-19 that maximizes available medical resources for at-risk members" said Amar Gurivireddygari, BCBSRI chief data and analytics officer.

While the BCBSRI COVID-19 dashboard has been used for tracking and analyzing trends, it’s also been used by BCBSRI’s care management team to enhance communication, education and support for members. The dashboard has also been used by BCBSRI’s systems of care, such as Coastal Medical, to inform their outreach to at-risk members.

The dashboard incorporates the CDC’s Social Vulnerability Index (SVI), which helps to recognize and better understand who may face less urgent or less obvious challenges. Social vulnerability refers to the resilience of communities when confronted by external stresses on human health. The index utilizes the CDC's 15 U.S. census variables, such as those who live in densely populated housing and who might lack transportation, or those who live with someone under 17, someone over 65 or someone with a disability.

It was this component that helped Coastal Medical identify patients who had not been classified as vulnerable in the past, but due to COVID-19, were now falling into that category and were suddenly vulnerable. According to Sarah Thompson, PharmD, MBA, MHL, Coastal Medical’s vice president of clinical operations and pharmacy, “The dashboard gave the Coastal team insight into the social determinants of health and health inequities that could be impacting patients who already were dealing with a chronic condition or behavioral health issues."

Thompson added, “The dashboard gives us a broader view of our patients, allowing us to provide outreach to every single vulnerable patient and connect them with the right sources within our Coastal system. This effort included our primary care providers and offices, nurse care management, behavioral health and our pharmacy teams."

For BCBSRI, the SVI data gave them a different view into the insurer’s membership.

“We know many Rhode Islanders are already connected with a nurse case manager if they have severe health issues or are at a great risk for COVID-19," said Ivette C. Luna, BCBSRI manager of consumer engagement. “But what about those people who might be otherwise healthy, but have a less urgent need that, left unchecked, might lead to a larger health risk? Those are the people we wanted to reach out to utilizing the SVI data."

The BCBSRI consumer engagement team made nearly 1,000 calls in the first wave of SVI outreach, connecting with 30 percent of those called. The team helped members connect with mail order medication refill services, download a telehealth app on their phones or utilize a wellness reimbursement to stay active while at home.

According to Luna, the consumer engagement team and BCBSRI’s retail team found that the people they reached didn’t have a critical need, such as food assistance, and they had a good support system and were able to stay safe at home during the pandemic.

“What we did find is that members were so appreciative to learn about the resources available to them, both from Blue Cross and a myriad of community resources," said Luna. “One of the most important reminders here is that we need to keep checking in with each other. One woman told a member of our team that she was the only person she had spoken to all day."

To learn more about BCBSRI’s efforts related to COVID-19, please visit www.bcbsri.com/keepinformed/