AI Used to Identify High Risk COVID-19 Safety Net Patients in Cook County

Monday, March 16, 2020 Tropical Disease News
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Medical Home Network's community-based care teams proactively reach out to high risk individuals to offer help

CHICAGO, March 16, 2020 /PRNewswire/ -- For Medicaid beneficiaries in Cook County, understanding what measures to take to protect against or receive treatment for COVID-19 can be overwhelming if they are facing barriers, such as homelessness or lack of access to transportation.

Medical Home Network is building on its predictive health risk screening approach in partnership with, healthcare's data science platform, to identify Medicaid patients who are at the most risk from COVID-19.'s COVID-19 Vulnerability Index or an AI-based predictive model was used in combination with MHN ACO's patient demographics, social determinants of health, claims and clinical activity to create a predictive model that allows MHN to prioritize care management outreach to patients who are likely to have a heightened vulnerability to severe complications from COVID-19.

"We want to identify what we refer to as the 'socially isolated' or people without nearby friends or family so our care teams can proactively educate and offer assistance to people in regards to COVID-19," said Dr. Art Jones, Chief Medical Officer at Medical Home Network

Medical Home Network's Accountable Care Organization (MHN ACO) provides high-quality managed health care to approximately 120,000 Medicaid patients in Cook County. MHN ACO provides patients with better care through coordinated care management at the practice level.

Patients who have been identified as high risk for severe complications from COVID-19 infection will be contacted by MHN ACO care management teams who are employed by their primary care practices based in communities across Cook County and have built trusted relationships with patients.

"Community preparedness is critical. The dedicated MHN care teams who proactively reach out to patients via phone, email or text will help individuals understand what they can do to lower their chance of infection, recognize symptoms of infection and how best to access the advice and care they need," said Jones.

Medical Home Network ACO, includes ten Federally Qualified Health Centers, three hospital systems, and their physician practices.

"With limited availability for testing at present and the stress this pandemic will place on our health care system, we need ways to identify individuals that will most benefit from outreach. Medical Home Network is using our health risk data which includes social determinants of health powered by AI predictive models to prioritize resources in our communities," said Cheryl Lulias, President and CEO, Medical Home Network. "Our care teams can make a difference for those patients who are likely to have a heightened vulnerability to severe complications from COVID-19."

About Medical Home NetworkMedical Home Network is transforming health care delivery for Medicaid patients by fostering collaboration and innovation. Our proven model of care unites communities of providers and patients around a common goal: To redesign health care delivery and transform the way care is delivered and managed, resulting in improved patient care, lower costs and better health in the communities we serve. MHN can be found online at and on LinkedIn at

About Medical Home Network Accountable Care OrganizationMedical Home Network Accountable Care Organization (MHN ACO) is a provider-owned and driven approach to patient-centered healthcare delivery and population health management for Medicaid patients. Our members include ten Federally Qualified Health Centers, three Hospital Systems, and their Physician Practices. Within our ACO we strive to create a different kind of culture – one that includes shared decision-making and is focused on change, innovation, collaboration and delivery improvement for all our member/owners. For more information, visit


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