Report: Low-income, high-risk patients less likely to close care gaps, benefit most from one-on-one outreach

Low-income patients with chronic conditions may be less likely to close care gaps than their high-income counterparts, underscoring long-standing concerns about the impacts of social determinants of health on high-risk patients, according to an athenahealth report.

Athenahealth, an electronic health record and practice management company, found that in an analysis of 7 million patients, high-risk patients—those with two or more chronic conditions—were less likely to schedule annual wellness visits last year if they lived in a low-income zip code.

Of the 4.6 million high-risk patients included in the study, all of whom had an annual wellness visit in 2019, 39% of high-risk patients in high-income zip codes scheduled a wellness visit in 2020 within the 90-day eligibility window, compared to 33% of high-risk patients in low-income zip codes.

The findings highlight a concerning reality in ensuring care for patients with chronic conditions, who are already more likely to live in low-income zip codes and face systemic barriers to sufficient healthcare like a lack of insurance.

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The study also showed a lower care gap closure rate at federally qualified health centers, which typically serve lower-income communities with diminished access to outpatient clinics.

Athenahealth conducted over a dozen interviews with physicians, care managers and other providers to consider the role of technology in caring for high-risk groups. Jessica Sweeney-Platt, athenahealth’s vice president of research and editorial strategy, said the providers agreed that one-on-one, provider-to-patient communication was especially critical for engaging high-risk patients.

“Personalized outreach and tailored approaches—there’s no substitute for that,” she said.

She added that while some aspects of healthcare technologies, such as automated notifications sent to patients when they’re due for a visit, are “not necessarily the thing that is generating the biggest impact for those patients,” those capabilities can help reach lower-risk patients and free up the provider’s time to connect with high-risk patients who may benefit far more from a one-on-one phone call.

The providers said these technologies do have a place in their practice, Sweeney-Platt said, but that their use should be informed by personal knowledge of the patient and their preferences—whether a specific patient would rather respond via text than over the phone, for example.

“It is less about ‘technology doesn’t work,’ but more about, if you’re going to use technology as a part of the communication strategy, if you’re going to use digital outreach, it needs to be because it’s the right channel for that patient, not because it’s just the most convenient thing to hit a single button and send out a dozen messages,” she said.

One reason for optimism, however, emerged from the study: Patients with chronic conditions were more likely to close their care gaps and to arrive on time to their wellness visits, with 21% of patients with chronic conditions closing care gaps compared to 18% of those without.

“If you are a patient with chronic disease, you understand the impact that delay in care can have. It does seem like you are slightly more likely to take care of these preventive services on time, at least in this analysis,” Sweeney-Platt said.

Because the study analyzes patient information from athenahealth’s electronic health record system, however, patients who have even less access to care—in this report, those who didn’t seek an annual wellness visit in 2019—wouldn’t show up in the analysis in the first place. Sweeney-Platt acknowledged this limitation.

The providers surveyed told athenahealth that telehealth flexibilities, expanded during the COVID-19 pandemic to increase access to virtual care, have been instrumental in allowing practices to connect with high-risk patients.

“A lot of people are saying that if we never have to give that up, we never will,” said Sweeney-Platt.