Improve Patient Care By Coordinating Virtual Outreach Teams with Health Plans


A session from the 2021 PQA Annual Meeting highlighted the benefits of virtual outreach in advancing patient care amid the COVID-19 pandemic and beyond.

virtual patient care

The COVID-19 pandemic has created myriad hurdles to providing patient care across the spectrum of health care. While the low rates of annual wellness visits have mostly rebounded, several studies have reported that some screenings, such as those for colon cancer and diabetes, are still down as much as 60%.

In a session presented during the Pharmacy Quality Alliance (PQA) 2021 Online Annual Meeting, which took place from May 11-13, Anna Hall, director, Quality Services, Enhanced Medication Services and Laurin Dixon, director, Medicare Star Ratings, Arkansas Blue Cross and Blue Shield (ABCBS), explored the various models of pharmacist-delivered care that can address the low rates of annual wellness visits, cancer screenings, and diabetic evaluations.

“Typically, annual wellness visits are a key factor in care of members and making sure they receive quality treatment and evaluations across all of their health conditions annually,” Dixon said. “These interventions help pinpoint potential care gaps and ensure that the holistic disease management is evaluated and intervened on.” However, the pandemic severely limited annual wellness visits as physician offices closed. And, even once offices reopened, patients, particularly those who are older or with comorbid conditions, were reluctant to go back into the in-person setting.

Dixon explained that in her state of Arkansas, some mammogram centers and colonoscopy screening locations were closed for 5 months or more in 2020. By the middle of the third and into the fourth quarter, though, many providers were resuming care, and “Arkansas Blue Cross collaborated across the state with provider offices and other centers to encourage a return to care if people had been previously delaying this,” Dixon said, who explained that many reluctant patients were still looking for at-home options to speak with clinicians. 

Based on the gaps the clinicians and providers were seeing, ABCBS focused their program on the following screenings, and specified these Healthcare Effectiveness Data and Information Set (HEDIS) measures:

  • Breast cancer screening – evaluate the percentage of women 50-74 years of age who had a mammogram between October 2018 and December 2020.
  • Colorectal cancer screening – evaluate the percentage of members 50-75 who had appropriate colorectal cancer screening, either as a colonoscopy every 10 years; a Cologuard kit every 3 years; or a fecal occult blood test (FOBT) at home each year.
  • Eye exam as part of comprehensive diabetes care – evaluate the percentage of diabetic Medicare Advantage (MA) enrollees 18-75 who had a retinal exam performed during the measurement year.
  • Medical attention for nephropathy as part of comprehensive diabetes care – evaluate the percentage of diabetic MA enrollees 18-75 who had medical attention for nephropathy during the measurement year.
  • HbA1c control as part of comprehensive diabetes care – evaluate the percentage of diabetic MA enrollees 18-75 whose most recent HbA1c level is greater than 9%, or who were not tested during the measurement year.

Hall discussed the collaborative intervention model for the program, which included a clinical service center made up of a team of pharmacists, technicians, and member engagement specialists who worked in coordination with Dixon’s Quality team at ABCBS.

“In 2021, we will also incorporate our network of community pharmacists that share a clinical intervention platform integrated directly into the pharmacy dispensing platform to engage members with gaps through their personal pharmacist in a value-based payment model,” Hall said.

In 2020, members were engaged through a live-telephonic outreach model that carried out customized and comprehensive interventions while many individuals were quarantining at home. The clinical services intervention team was able to see each targeted gap in care that had been flagged for a given member at the same time and generate specific intervention protocols aimed at closing the gap.

Hall highlighted the processes for engaging members who were not up to date on breast cancer or colorectal cancer screenings. Patients flagged for a mammogram were contacted by a team member, who assisted the patient throughout the process of scheduling the screening. For those behind on their colorectal cancer screening, “we offered the chance to provide the member with an in-home FIT kit, or fecal immunochemical test, that they could complete very easily in the comfort of their own home and mail in for the results,” Hall explained. She reported that members appreciated the ease of the test, as well as the ability to complete it from home.

For members with diabetes that had not continued regular screenings during the height of the pandemic, Hall and the intervention team created a live-telephonic diabetes comprehensive care outreach intervention program that addressed the multiple gaps in care related to diabetes.

“The importance of each screening and the reason for the discussion was covered with the member and the clinical services team member,” Hall said. The outreach team offered the patient information on any recent screenings and provided information for members reporting previous eye exams, kidney screenings, or HbA1C tests to ABCBS in order to locate medical records.

“We also used the opportunity while having the members on the phone to discuss gaps in care for those without any current claims for a statin medication,” Hall said, where the team evaluated whether a statin prescription would be appropriate in members with no contraindication.

Similar to the process for breast cancer and colorectal screenings, the intervention team helped members needing an eye exam in scheduling an appointment. Patients that were overdue for the HbA1c and kidney disease screening, or who had HbA1c levels over 9, were able to receive a convenient at-home testing kit.

The testing kits all included a letter from the member’s health plan reminding them of why they’re receiving the kit, as well as a specific set of instructions with pictures in order to facilitate completion of the test and prepaid posting for when the patient is ready to send back the kit. “They’re all very convenient and allow the member to obtain the screening without ever leaving home or…having to worry about COVID exposure, which may had been the reason that some of these members had not received screenings at the provider’s office during the pandemic,” Hall said.


  1. Hall A, Dixon L. Pharmacists Get Creative! Overcoming Barriers to Care by Going the Extra Virtual Mile. Presented at: Pharmacy Quality Alliance 2021 Online Annual Meeting; May 11-13, 2021; virtual. Accessed May 12, 2021.

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