• Rebecca S Goldstein, Alyssa R Greenhouse, Anjali Om, Carson R Ward, Leslie Marshburn, Cinnamon D Bradley, Tracey L Henry, and Maura George.
• Emory University School of Medicine, Atlanta, GA, USA. rsg95@cornell.edu.
• J Gen Intern Med. 2022 Aug 1; 37 (11): 266126682661-2668.

IntroductionCOVID-19 disrupted access to critical healthcare and resources for many, especially affecting patients at safety-net hospitals who rely on regular care for multiple complex conditions. Students realized they could support patients from the sidelines by helping navigate abrupt healthcare changes and proactively addressing needs at home.AimTo comprehensively identify and meet the clinical and social needs of Atlanta, Georgia's patients at highest risk, left without their usual access to healthcare, through proactive telephonic outreach.Setting And PatientsMedical and Physician's Assistant students from Emory and Morehouse Schools of Medicine partnered with Grady Health System, Atlanta's safety-net hospital. Artificial intelligence prioritized over 15,000 patients by risk of morbidity and mortality from COVID-19.Program DescriptionIn this novel program, students performed telephonic outreach to thousands of patients at highest risk of poor outcomes from COVID-19. Students used a custom REDCap form that served as both a call script and data collection tool. It provided step-by-step guidance to (1) screen for COVID-19 and educate on prevention; (2) help patients navigate health system changes to fill gaps in care; and (3) identify and address social needs. Based on patients' responses, the form prompted tailored reminders for next steps and connections to medical and social resources.Program EvaluationIn the program's first 16 months, students made 7,988 calls, of which 3,354 were answered. Over half (53%) of patients had at least one need requiring action: 48% health and 16% social.DiscussionThis proactive, novel initiative identified substantial clinical and social need among patients at highest risk for poor outcomes and filled a pressing health system gap exacerbated by COVID-19. Simultaneously, interprofessional students gained applied exposure to health systems sciences. This program can serve as a model for rapid, cost-effective, high-yield outreach to promote patient health at home both during and beyond the pandemic.© 2021. The Author(s) under exclusive licence to Society of General Internal Medicine.

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