Identifying Patients with Increased Risk of Severe Covid-19 Complications: Building an Actionable Rules-Based Model for Care Teams

Alina S. Schnake-Mahl
Marcy G. Carty
Gerardo Sierra
Toyin Ajayi
Peer-Reviewed Article
May 2020

Cityblock Health provides care to populations with high rates of social, behavioral, and health risk factors, many of whom are at higher risk for complications from COVID-19. Cityblock developed a model to identify high-risk members to target education, services, and symptom management to individuals most in need, and this open-source tool is included in this resource so other providers and health care organizations can do the same.

The model uses simple rules and criteria from evidence-based sources to categorize patients based on risk level. Care teams follow up with high- and medium-risk patients who are then assessed for COVID-19 and social risk factors potentially exacerbated by the pandemic. Responses to these questions help target medical care, resources, education, and social services. In addition, Cityblock partnered with local courier services and mutual aid providers to get patients the supplies they need.

Using this model offers the potential to better understand the patient population; prioritize outreach and care for vulnerable patients; forecast potential hospital bed shortages; estimate hospitalization and intensive care unit use; and identify socioeconomic and racial inequities in adverse outcomes for those with COVID-19.

Posted to The Playbook on