Case Study: Johns Hopkins Medicine achieves rapid identification and outreach to high‑risk Medicare Advantage patients with SS&C Technologies' ACG System

How Johns Hopkins HealthCare identified high-risk patients for outreach, using the ACG® System

Johns Hopkins Medicine’s managed care arm, Johns Hopkins HealthCare, faced the urgent challenge of identifying and supporting the Medicare Advantage members most vulnerable to COVID‑19 complications across a 25,000‑member plan. Working with the ACG® System distributed by SS&C Technologies, the team quantified risk (about 60% with at least one risk factor and a 5% most vulnerable cohort) to prioritize outreach for elderly and chronically ill patients.

Using SS&C Technologies’ ACG System risk stratification and markers, Johns Hopkins generated prioritized outreach lists, redeployed care managers and community health workers, built EMR assessment workflows, and coordinated telemedicine and medication access. The program contacted over 4,500 members, with the clinical team reaching 2,600 and engaging more than 80% of those targeted; 52% completed in‑depth barrier assessments. The intervention met goals of contacting the top 20% most at‑risk quickly, reduced pharmacy trips for many members, and saw telemedicine use at Hopkins PCP sites jump from under 10 visits/month pre‑COVID to over 3,000/month in April–May.

Johns Hopkins Medicine

Sonia Munn

Director of Care Management