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Measuring and Maintaining Wellness During a Pandemic

Multidisciplinary team at UC San Diego Health develops a program to connect with and assist high-risk older patients sheltering in place, often alone

By Jeanna Vazquez   |   May 20, 2020

Across the country and world, many individuals are dealing with the COVID-19 pandemic by sheltering at home with family, but some must cope alone. Daily tasks like grocery shopping or managing prescriptions can be challenging, but for populations most at risk, such as seniors over the age of 85, these necessities may be impossibly daunting. 

nursing student
Spurred by concern for seniors in San Diego, Parag Agnihotri, MD, chief medical officer at UC San Diego Health Population Health Services Organization, gathered a team to begin checking on patients, often by simply calling them to see how they were doing.

"With key, evidenced-based structured questions related to medications, social support, food on hand and ability to manage stress or anxiety during this time, our team began conducting phone calls to our high-risk senior patients,” said Agnihotri. “The outreach included coordination with other departments, such as social work, nursing and pharmacy as needed, with urgent issues handled by an onsite nursing instructor who could bring in our nurse triage team or 9-1-1.”

The response has been overwhelmingly positive. Patients were able to refill needed prescriptions. They got help ordering groceries. Some just welcomed an opportunity to talk with someone.

Responding to a need

Called “The Wellness Project,” the program began March 23 with a small team of quality care navigators and registered nurses conducting the calls. But the team soon realized the need for this kind of outreach was far greater than they thought.

“We started the calls wanting to make sure our senior population currently sheltering in place at home had what they needed and knew we are here to help,” said Eileen Haley, MSN, RN, director of Population Health at UC San Diego Health. “When we reviewed the results of the calls, we saw the value and realized we needed to expand upon our efforts.”

In partnership with the Nursing Department of Education, Development and Research at UC San Diego Health, Haley and colleagues in the Wellness Project provided nursing students with the opportunity to join the evidence-based program, which helps meet Board of Nursing requirements and provides clinical hours for students whose academic careers have been disrupted by the COVID-19 crisis.

By late-April, three nursing schools and five 10-member teams of students were conducting daily calls from a central site, all safely distanced. The program has expanded to include family medicine residents as well. More than 600 patients have been contacted and worked with a team member. This pilot program and others like it will continue throughout the year, with plans to expand to other nursing schools at local Universities in the future.

“We are training nurses and physicians of the future, and helping them understand the impact of how medical, physical and social determinants factor into a person’s health and well-being,” said Haley. “We’re proud to play such a key role in helping provide health care to our patients at an individualized level.”

Virtual connection develops a social bond

Agnihotri and Haley

Parag Agnihotri, MD, chief medical officer at UC San Diego Health Population Health Services Organization and Eileen Haley, MSN, RN, director of Population Health at UC San Diego Health.

A subset of the senior population in San Diego are considered high-risk with multiple medical, physical and social needs, especially those living alone with minimal social networks or support. The Wellness Project provides an opportunity for clinicians and students to listen, learn and help connect patients to their doctors, pharmacists or social workers. It also provides patients with the opportunity to just talk with someone about their concerns, fears or even what they may be making for dinner that day.

“One student recently connected with a scared and lonely patient who had not had any social contact by phone or in-person for more than two weeks,” said Agnihotri. “For an hour, this student shared CDC-recommended guidelines for health and safety, answered the patient’s questions and let her know that she cared.”

The program also provides nursing students with an opportunity to more deeply learn about UC San Diego Health’s value-based care efforts, develop a greater understanding of COVID-19’s impact on health care and use multiple technologies to reach out to patients sequestered at home.

“As the region’s only academic medical center, and with our population health expertise, we see this as a valuable learning experience for students, our patients and our team,” said Agnihotri. “We will continue this work, with the goal to expand to other learning opportunities that relate to population health and our community while we continue to face the COVID-19 crisis.”


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