In April 2020, a social worker (S.L.) and an infectious disease physician (D.A.S.) met with a group of medical students to design a telephone outreach program for patients with HIV connected to care at the Infectious Diseases Clinic at Brigham and Women’s Hospital (BWH) with the following goals:
(1) Screen vulnerable patients for acute medical and social needs during the pandemic.
(2) Provide patients individualized Covid-19 education.
(3) Provide direct referral to social services, including food assistance and low-barrier, easy-access Covid-19 testing.
(4) Provide students an opportunity for direct patient care within an interprofessional framework.
(5) Teach students principles of motivational interviewing with opportunity for practice, observation, and feedback.
(6) Offer students real-time Covid-19 clinical updates in the context of the rapidly evolving pandemic.
To standardize outreach calls and provide language and screening tools around structural drivers of health (SDOH), the physician and social worker developed a semi-structured script based on principles of motivational interviewing (Appendix 1).9 Three students were monolingual English speakers, two students were bilingual in English and Spanish, and one student was bilingual in English and Haitian Creole. This allowed for English, Spanish, and Haitian Creole-speaking patients to receive language-concordant outreach. For discordant language pairings, students used a licensed medical interpreter to communicate with patients.
Process (Figure 1)
Using a clinic registry, clinicians and social workers in the clinic identified patients as candidates for outreach calls based on prior history of need for social support or history of social isolation.
The students each called five unique patients every week. Students made initial connections to food assistance, social services, and Covid-19 testing during calls. Patients expressing a desire for more social connection were offered information about virtual support groups. The student entered a note summarizing the call with “action items” for follow up into the electronic medical record that and sent the note to the patient’s social worker and physician. We sent face masks to all patients without access. Members of the team met virtually every week to debrief the outreach calls, troubleshoot challenges, revise the semi-structured script based on evolving patient needs, and evaluate student experiences.
The weekly team meetings began with a didactic session tailored to the needs of the program and the interests of the students. The educational focus at the beginning of the pilot was the development of clinical skills through interactive sessions on the principles of motivational interviewing and best practices for engaging patients around structural drivers of health in the virtual setting. The focus of the sessions then shifted to clinical updates on Covid-19 including epidemiology, clinical manifestations of infection, transmission dynamics and disease prevention, impact of Covid-19 on patients with HIV, novel therapeutics, and the evolving landscape of diagnostic testing.
Legend: Orange boxes represent steps in the workflow; yellow triangles represent key decision points.
We reviewed all notes from student outreach calls conducted between April 1, 2020 and July 15, 2020 to evaluate the scope of outreach to patients. We recorded data on patients’ age, gender, and preferred health care language. We defined successful outreach to patients as confirmed contact with the patient. For analysis, patients were divided into two age groups, age < 60 or age ≥ 60 to determine whether successful outreach was different by age group. The BWH IRB reviewed the project and deemed it exempt.
During weekly meetings students identified shared themes that emerged during outreach calls including the shifting needs of patients as the pandemic evolved, and the impact of the calls on students and clinicians.