A Northeastern Minnesota health care nonprofit is reaching out to at-risk populations during the COVID-19 pandemic.

Using a state-provided dataset, Wilderness Health is identifying and contacting people on Medicaid who are potentially vulnerable to complications if they become sick with COVID-19. Its leaders hope to keep this population healthy through targeted resources and support, as people on Medicaid already face numerous barriers to health.

Wilderness Health is a collaboration of 10 local, independent health care providers, including St. Luke's hospital in Duluth, Community Memorial Hospital in Cloquet, Lake View Hospital in Two Harbors and Fairview Range in Hibbing, that work to advance the health of rural communities, Executive Director Cassandra Beardsley said.

Using the dataset, Wilderness Health identifies at-risk patients by their chronic conditions, like heart disease, hypertension and obesity, as well as by their living conditions, like homelessness or housing instability.

With most people in isolation, they've found that some patients have missed regular care visits or ceased maintaining their preventative health measures, which could result in "pretty severe" health consequences, Wilderness Health Medical Director Dr. Gretchen Karstens said.

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"We found it really important ... for our clinics to be able to have access to these patient rosters where they could do some outreach in a time where there's so much going on," Karstens said.

Patients on Medicaid are more likely to encounter health problems and housing troubles, as they have access to fewer resources – like stable transportation and work hours, Beardsley said.

The providers ask patients about their living situations, if they're taking prescribed medicine, how they're maintaining relationships, the status of their mental health and more.

Answers to these questions can spark a follow-up virtual appointment or providers will help their patients access other resources, such as those related to housing, Karstens said.

Dr. Nathan Chomilo is the state's Medicaid medical director. He and his colleagues began developing the program when patients with risk factors started appearing at emergency departments with far more serious COVID-19 symptoms than most other patients, Chomilo said.

They wanted to create a program that didn't just look at a patient's individual health, but also an individual's social side, Chomilo said.

"Are there ways that they might be starting to struggle with housing instability and security? Are there ways and resources that we can connect them to keep them stably housed?" he said.

The Minnesota Department of Human Services makes the dataset available as part of its Integrated Health Partnership, which Wilderness Health has been a member of since 2015.

Chomilo has heard a number of success stories from the 26 Minnesota health care systems using the dataset. He's also heard stories of patients thanking their providers for reaching out, as they've been mostly isolated and need social connection.

Wilderness Health has also seen patients grateful for social connections, while providers are finding new ways to connect with their patients.

One physician told Karstens that when visiting virtually with a patient, he noticed a photo of a World War II-era plane hanging behind the patient and asked him about it.

The man became choked up when sharing his WWII experience, acknowledging the guilt that's lingered with him ever since. It's a story and understanding of the patient that the provider said he wouldn't have ever heard without seeing the photo, Karstens said.

"There have been pieces of that mandated switch (to virtual) ... that have opened doors," she said.

Chomilo believes the best way to address barriers to health is through this new proactive approach, which he said he hopes continues on after the pandemic.

"My hope is that ... there's a place in that to (also) address ... the kind of issues we've seen with racial inequities and structural racism and how we're waiting for certain communities to show up (to receive care), instead of going and actually teaching them earlier," he said.