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Analytics and outreach key to telehealth success at Southwestern Health Resources

Southwestern Health Resources in Dallas, Texas, is a clinically integrated network with 5,500 community providers and more than 700,000 covered lives in North Texas. As a value-based care organization, it provides population health management for its parent organizations, Texas Health Resources and UT Southwestern Medical Center.


When the pandemic began, Southwestern was very concerned about its most at-risk members. Primary care providers saw a more than 50% drop-off in volumes during the second quarter of 2020. The people who most needed their doctors were also the most likely to shelter in place and not seek care.

As patient volumes plummeted, Southwestern also recognized an increased risk to quality improvements due to the long-term impacts of undiagnosed cancers and other disease progressions among the people it serves.

“So we needed to ensure our community PCPs could connect to patients who most needed them, as well as support outreach to all patients for preventive care,” said Dr. Anthony Ziskind, senior executive officer of Southwestern Health Resources. “Continuity of care, especially for complex patients, is at the heart of what we do. And telehealth, which had not played a significant role in patient care previously, was the clear solution.”


Telehealth would enable Southwestern’s community physicians to reach out to at-risk patients, ascertain their needs, reassure them of their safety if they needed an in-person visit, or connect with community partners to deliver care in their home.

In early March 2020, the Southwestern operations response team created a network-wide command center to increase efficiency and provide patient outreach support to its provider network. The team quickly focused established communications channels with community providers – physician pod meetings, newsletters and more – on educating them in the use and reimbursement process for telehealth visits.

“The network has put out more than 200,000 targeted communications to patients at risk of heart attacks and strokes, urging them to avoid delaying access to acute care.”

Dr. Anthony Ziskind, Southwestern Health Resources

As nearly all the providers in the network are on the same EHR and the Southwestern platform, the organization could ensure the technology was integrated with both their technology and clinic operations.


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Simultaneously, Southwestern’s medical economics department applied advanced analytics and actuarial capabilities to claims and EHR data to identify elderly, medically complex and otherwise at-risk patients, then provided those lists to physicians for outreach via telehealth. The organization also provided each physician with a list of their patients who had missed mammograms, colonoscopies or other essential screenings because of the pandemic.

Then, PCPs could contact each individual by e-mail or, if additional reassurance was needed, via telehealth, to schedule their screenings.

“Patients were also alerted to the option of using telehealth to connect with their providers,” Ziskind noted. “We published patient education information on our website to facilitate telehealth visits and launched targeted patient communication across the network via telephone to explain the option of care by telehealth.”

Building patients’ trust in telehealth and walking them through the process was essential to creating volume, he added. The message to all patients remains threefold:

“Other messages to patients included underscoring the value of telehealth as an equally high-quality alternative to in-person care and communicating about the wide range of treatment options that are available in this format,” he said. “Addressing insurance coverage concerns was also a large part of our messaging to reassure patients that we are able to care for them under most insurance plans – mitigating cost-related fears.”


The work of the Southwestern operations response team quickly enabled telemedicine across its community practices, with approximately 8,000 virtual visits per day across the network. Southwestern activated around 500 independent practices in telehealth capabilities in less than one month. The response team also coordinated check-in calls to at-risk patients, reaching 4,000 monthly patient connections by May 2020.

“The network has put out more than 200,000 targeted communications to patients at risk of heart attacks and strokes, urging them to avoid delaying access to acute care,” Ziskind said. “Using analytics from claims and EHR data, there has been additional outreach of 250,000 amplified messages to patients and members in high prevalence ZIP codes to amplify the prevention of COVID-19 infections in underserved communities, with a second wave to all 700,000 network patients planned.”

Southwestern outreach enabled by data analytics and telehealth as of July 2020 entailed:

  • Education of at-risk and high-risk patients to avoid delays in acute care (170,000+ outreach).
  • Education of patients and members from high-prevalence ZIP codes (10,000+ outreach) on controlling the spread of COVID-19, and now network-wide (700,000+ outreach planned).
  • Screening of COVID-19+ patients for social determinants of health (1,200+ completed).
  • Vendor and provider partnered quality gap closure effort (underway).


“Population health management – and its core components of care delivery innovation, patient monitoring, advanced analytics and value-based payments – present a lifeline during the pandemic in part due to the flexibility of delivering an immediate intervention of scaling telehealth and virtual care across our network,” Ziskind explained. “The technology was able to provide personalized care remotely, the exact balance required in these circumstances.”

Three keys to success, he noted, were:

Twitter: @SiwickiHealthIT
Email the writer: [email protected]
Healthcare IT News is a HIMSS Media publication.

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