Using Data to Identify Unvaccinated Members and Prioritize Outreach

Date: July 22, 2021
Time to read: 6 minutes.

Individuals dually eligible for Medicare and Medicaid are disproportionately impacted by COVID-19, and health plans recognize that this population is at greater risk of adverse health outcomes from COVID-19 infection than the general public due to the complexity of their health and social needs. Many health plans are utilizing data analytics and visualization tools to identify their members with the highest risk of adverse health outcomes if unvaccinated and to target sharing of resources related to COVID-19 vaccination with those members.

Health plan strategies to identify, prioritize, and educate the most vulnerable still needing COVID-19 vaccination:

  • Data Dashboards Identify Vaccination Gaps: A number of health plans have created COVID-19 “dashboards” using key data points extracted from their internal claims and demographic data, as well as the latest available local, state, and national vaccination data (e.g., the Centers for Disease Control and Prevention (CDC), World Health Organization, Johns Hopkins University, and others). Data dashboards are utilized by health plan care coordinators or other teams to implement and prioritize vaccination outreach campaigns.
    • These COVID-19 dashboards commonly include member data points such as: vaccination status, complex/chronic conditions, COVID-19 diagnoses, hospitalizations, intensive care unit stays, race, ethnicity, age, gender, spoken language, income status, and homebound status.
    • One plan works closely with their health economics team and their state to review weekly updates on how many and which of their members, by product type, are vaccinated, sick, or hospitalized.
    • To additionally identify health disparities as part of the risk stratification process, some plans incorporate the CDC Social Vulnerability Index,1 Community Needs Index 2 or the California Healthy Places Index.3 These databases help health plans identify and map those communities likely needing support during natural disasters or pandemics due to poverty, insufficient access to transportation, crowded housing, cultural barriers, and other factors.
    • Some plans’ dashboards also include geographic maps of COVID-19 viral loads to identify areas of peak infection to further prioritize education and outreach to those high-risk areas.
    • The frequency of the dashboard dissemination to internal outreach teams varies by plan – some dashboards update in real time, others as frequently as weekly, and others as the latest updated information becomes available from local, state, or national sources.
  • Targeted Outreach Using Data Dashboards: Health plans rely on existing care coordination teams or newly developed “rapid response” teams to prioritize and implement their outreach. Several plans use a risk stratification methodology within their data dashboards to further assist teams to prioritize and customize outreach to members with high, medium, or low risk of adverse health outcomes. Staff make phone calls to the highest risk members or their caregivers to assess their latest vaccination status, offer resources to keep members safe if they choose to not be vaccinated, explore any vaccine hesitancy, provide education, and/or assist scheduling appointments (including transportation).
    • In addition to individual outreach, dashboards help health plans understand community segments with higher infection rates or other risk factors. One plan stated that the disparities they see in preventive care map closely to the disparities in COVID-19 vaccine access, and they focus their outreach efforts in those areas and customize messaging to specific communities. Understanding this information further provides opportunities to collaborate with large housing complexes, counties, public health offices, and other local organizations, and offer targeted “pop-up” vaccination clinics or home visits to clusters of homebound members.
    • One plan designated a specific vaccination team of community health workers and engagement specialists to provide outreach, and ensured that the team is culturally diverse and speaks the languages common to the local communities. This team regularly receives the dashboard data on vaccination and risk, then mobilizes to conduct targeted outreach, including visits to the community.
  • Data Sources and Activities to Address Local Vaccine Hesitancy: Health plans have indicated that some vaccine hesitancy is rooted in cultural barriers and experiences of specific local communities. Consequently, reasons for hesitancy vary across communities, even communities that may be geographically close but culturally very different.
    •  The U.S. Department of Health and Human Services provides a resource through their We Can Do This campaign, the COVID-19 Vaccine Hesitancy in Your Community map, which can help health plans identify vaccine hesitancy estimates by county, and includes additional facts to help understand targeted outreach areas.
    • Strong partnerships with community organizations contribute to addressing local vaccine hesitancy, as does the use of motivational interviewing techniques and willingness to engage in lengthy 1:1 conversations with members and caregivers.
  • Lessons Learned to Enhance Data Use and Targeted Outreach: Health plans shared key lessons learned as they used data to deploy targeted outreach, including:
    • To address potential external data source lags, health plans need close collaboration with public health partners to establish processes to receive updated vaccination data as timely as possible.
    • “Cultural matching” of the outreach teams to the targeted populations is critical to the success of outreach efforts. By partnering with local community leaders/organizations, health plans ensure that staff on outreach teams are of the same culture and speak the same language as those being served.
    • Person-centered approaches are the most effective. By listening to individual members’ barriers to vaccinations, and educating both members and their caregivers, health plans are overcoming some vaccine hesitancy.
    • Health plans can efficiently develop and disseminate toolkits and resources by organizing available CDC information along with contemporary resources from community partners. One plan created a “confidence toolkit”, a reference guide for outreach staff, that enables them to quickly respond to specific vaccination concerns expressed by members or their caregivers. Health plans should review and update toolkits and resources at least monthly, and amplify the applicable state’s public health messaging as much as possible since it is “real time.”
    • Health plans should leverage existing relationships and processes as much as possible. Care coordinators can add COVID-19 vaccination screening and education related topics to the list of other topics during planned follow-up care management calls. If home visits are planned in a particular geographic area for other care coordination functions, they can also coordinate visits for members needing in-home vaccinations.
    • Health plans should not stop with a single outreach effort. Plans have found success with sending out reminder cards and making phone calls to ensure that the second vaccination dose was scheduled. Be sure to document the reason why members are initially declining the vaccine to inform future outreach efforts.

[1] Centers for Disease Control and Prevention. (2018). CDC’s Social Vulnerability Index (SVI). Agency for Toxic Substances and Disease Registry. Retrieved from

[2] IBM Watson Health. (2020). 2020 Community Needs Index.

[3] Public Health Alliance of Southern California. (2021). California Healthy Places Index. Retrieved from