Standard of Care | Multi-component health program |
---|---|
Aligned with patient-centered medical home components and quality-of-care measures | Community Weaver led Co-Creation Overarching strategy |
Care coordination | mHealth Outreach |
• Routine immunization efforts • Annual physical exam • Eligibility: defined medical conditions (e.g., uncontrolled diabetes, hypertension), high health services utilization (e.g., > 5 medications), social determinants of health and referred by care team | Community outreach led by Community Weavers via SMS and voice messages about COVID-19 vaccines (importance, reminders, how to access) and preventive services engagement (importance, reminders, how to access) in languages spoken by patients (i.e., Spanish, Arabic, Vietnamese) |
 | Care Coordination |
 | Inclusive of standard of care coordination with added focus on completing outstanding preventive services (e.g., HbA1c, blood pressure screenings, mammograms, colorectal cancer screening) |