The Heart of Care: Removing Roadblocks to Help a Vulnerable Patient Stay Home

April 17, 2020

In mid-March, as the COVID-19 pandemic began spreading rapidly across the country, "Edward" was trying to get everything he needed to stay at home for a month or more. The Florida Medicaid recipient has a complex medical history, including chronic obstructive pulmonary disease, heart failure and diabetes, that makes him extremely high risk for serious harm or death from COVID-19.

Yet, when Edward arrived at the pharmacy to pick up one of his many critical medications, he was informed that he would have to pay out of pocket. It was too early to get the refill cost covered by his health plan, the pharmacist told him.

Unable to afford the payment, Edward called Evolent RN Care Advisor Sara Plucker, who had supported him through a care management program months earlier, following a series of hospitalizations. Knowing the dangers Edward faced from both his chronic diseases and COVID-19, she immediately began looking for a solution to the refill issue, by reaching out to a colleague overseeing the pharmacy plan. That colleague, in turn, contacted the outside pharmacy chain.

After a rapid series of phone calls, the Evolent team zeroed in on the reason for the roadblock. While the Evolent Pharmacy team had already implemented an emergency override program to allow for early refills, in the turmoil of the country's initial response to the pandemic some pharmacies had trouble keeping up with all the changes. During the declared state of emergency, the retail pharmacy computer system was supposed to allow prescriptions to be refilled up to 30 days before the patient's supply was exhausted. However, this was a new process for some retail pharmacies, and in this case, the system limit had automatically defaulted to 14 days instead. 

The default setting was soon overridden and extended to 30 days. Sara contacted the retail pharmacy, and less than two hours after Edward called, he could obtain his refill without paying out of pocket. After his issue was resolved, the Evolent Pharmacy team ran additional testing to ensure that all other retail pharmacy systems were processing appropriately to prevent any further patient disruption.

Sara believes these actions, in the early days of the pandemic response, likely had an impact beyond Edward.

"Had he not called me, there could be many more people not getting their meds filled or having trouble paying for their medications," Sara says.

Formerly a nurse with the state department of health in South Dakota, Sara would regularly prepare for public health emergencies there during annual statewide drills. Two years ago, when she obtained her nursing license to work in Florida, she volunteered to support the state in an emergency if she was needed.

For now, she's among many Evolent employees seeking to reduce the pressure on the front-line clinicians in hospitals, by helping certain vulnerable individuals obtain the food, medications and medical equipment they need to avoid contact with the community.

"It does make a difference," Sara says. "They're writing down the phone numbers we give them for community resources. They're asking questions. They're concerned."   

About The Heart of Care
Every day, members of Evolent's care management teams use their clinical expertise and problem-solving skills to help individuals overcome serious health challenges. The Heart of Care series tells stories from the field that highlight their dedication to patients. For more information, see the blog post by Evolent CEO Frank Williams.
Previous Article
Deploying Data to Prevent COVID-19 Cases…One Door Handle at a Time
Deploying Data to Prevent COVID-19 Cases…One Door Handle at a Time

Evolent is combining clinical data, social determinants of health and the latest evidence about COVID-19 to...

Next Article
The Heart of Care: Connecting Members to Critical Needs During a Pandemic
The Heart of Care: Connecting Members to Critical Needs During a Pandemic

A new food program helps a vulnerable woman stay at home and reduce her risk of exposure.