News & Events

Population Health Strategy Allows Tufts Medical Center Primary Care Practice to Effectively Manage COVID-19 Patients at Home

In the early stages of the coronavirus pandemic surge in Massachusetts, Tufts Medical Center’s Division of Internal Medicine and Adult Primary Care quickly and efficiently instituted an innovative population health strategy to manage the health of COVID-19 patients at home. The approach allowed the Tufts MC Primary Care team to provide these patients with outreach and close attention from medical staff in the comfort and safety of their own homes. The results of the initiative were summarized in a paper, “Primary Care Population Management for COVID-19 Patients,” which was published in the Journal of General Internal Medicine on July 27, 2020.

Dr. Blazey- Martin describes the difference between urgent and emergent careAs the number of COVID-19 cases in Massachusetts began to increase in the second half of March, 2020, the Tufts MC Primary Care team knew that they would need easy access to up-to-date data to properly manage the practice’s patients with a confirmed COVID-19 diagnosis. Led by Deborah Blazey-Martin, MD, MPH, Chief of the Division of General Internal Medicine and Adult Primary Care and Liz Barnhart, NP, Primary Care Nurse Practitioner, the team quickly determined that a population health reporting structure was the best way to manage outreach to these patients, particularly during the most critical period, five to ten days after the onset of symptoms, when risk of respiratory distress and other severe symptoms was highest.

“Our practice became a Patient Centered Medical Home in 2013,” said Dr. Blazey-Martin. “As a result, we were already experienced with the population health tools required to proactively manage serious health conditions - such as diabetes, hypertension and substance abuse - in the community, rather than waiting for people to call and schedule an appointment.” 

The Primary Care team worked with Gabriela Andujar Vazquez, MD, Infectious Disease Physician and Associate Hospital Epidemiologist, to create a clinical algorithm, which Joseph Gillis Jr., Manager of Applications and LCO Analytics for the Division of General Internal Medicine and Adult Primary Care, built into the Primary Care electronic medical record. Less than a week later, by mid-April, 2020, the system was available to the entire practice. 

The strategy allowed the clinical care team to standardize and optimize at-home monitoring, support and care for COVID-19 patients, manage these patients’ health at home, and identify and quickly facilitate care for those who became so sick that they needed inpatient medical support. The approach also helped the caregivers identify the patients at the highest risk of complications and then focus their outreach on the period when patients were more likely to decline rapidly and require hospitalization. The team made upwards of 80 calls per day at the peak of the surge. By avoiding unneeded in-person contact, the caregivers also helped conserve masks and other personal protective equipment (PPE) at a time when they were in short supply.

To date, the Tufts Medical Center Primary Care team has managed 454 COVID-19 patients using this strategy; the vast majority of these patients have recovered from their illness.

“Our patients really appreciated the outreach and we received overwhelmingly positive feedback,” said Dr. Blazey-Martin. “This was a great example of how effectively population health works. This strategy allowed us to care for our patients with a new disease in a quick, streamlined and effective manner. If you are our patient and you test positive for COVID-19, you can rest assured that we are here to take care of you.”


About Tufts Medical Center
Tufts Medical Center is an exceptional, not-for-profit, 415-bed academic medical center that is home to both a full-service hospital for adults and Tufts Medical Center. Conveniently located in downtown Boston, the Medical Center is the principal teaching hospital for Tufts University School of Medicine. The Medical Center features a level one trauma center with rooftop helipad, the largest heart transplant center in New England and a renowned research program, ranking among the top 10 percent of independent hospitals to receive federal research funding. A physician network of 1,800 New England Quality Care Alliance doctors represents our strong commitment to health in the community. Tufts Medical Center is a founding member of Wellforce. For more information, visit