“It’s pretty hard to get a hold of your health when you are living on a park bench,” said Jeffrey Brenner, MD, a family physician in Camden, NJ, as he recalled an elderly patient who was approached by the Camden Coalition of Healthcare Providers, a non-profit network that brings medical care and social services to Camden’s poorest and sickest residents.
Brenner started the coalition in 2003 based on hotspotting, a data collection method that identifies “outliers” or people who return to the hospital repeatedly. The premise behind the coalition is that identifying frequently hospitalized patients allows for interdisciplinary interventions to minimize hospital trips, therefore, reducing cost while improving outcomes.
“In many large systems it turns out that a small number of individuals are driving up much of the cost and much of the utilization,” said Brenner, who noted that one patient went to a Camden-area hospital 113 times in one year and 324 times over five years. “Healthcare hotspotting is the strategic use of data to target resources to a small subset of high-needs, high-cost outliers,” he said.
The AAMC joined the Camden Coalition of Healthcare Providers and Primary Care Progress in 2013 to form the Interprofessional Student Hotspotting Learning Collaborative. Since then, the number of participating schools has almost tripled to 27, with 31 student hotspotting teams.
Student hotspotting exposes students to the social determinants of health while giving them experience working in interdisciplinary care teams,” said Victoria Sale, BSN, MSN, the coalition’s Cross Site Learning and Workforce Development clinical director. Many of the participating schools have begun accrediting this experience as a class, even choosing to adopt it as part of their curriculum, she added.
The hotspotting teams typically consist of one medical student, one nursing student, and one social work student, but may also include students from disciplines such as public health, dentistry, and in some cases, law, business, and anthropology.
“The idea is that a nursing student, a med student, a pharmacy student, and a social work student are all sitting alongside each other, actively problem solving with the patient” Sale said. “No one is higher or lower than the other, they are all really working towards common solutions.”
Creative problem solving
The Camden Coalition examines hospital data to identify patients frequently admitted to Camden-area hospitals. Student teams ask hospital staff in their respective communities to point out patients whom they treat regularly and who might benefit from hotspotting. Teams then meet with those patients in the hospital. If the patient is willing to participate, team members follow-up with them at home, at primary care appointments, and specialty care appointments. “They really help them to navigate the healthcare process,” Sale said.
The concept of health care hotspotting is data-driven, but the approach is personal. Over six months, students work closely with patients to better understand their complex health problems and how socioeconomics play a role. They build rapport to determine each patient’s specific needs. By getting to know patients in the hospital, and later at home, teams uncover what might have led to multiple hospitalizations. The goal is to draw a line between each patient’s story and their current state of health, Sale explained.
“Hotspotting efforts try to mirror actual interdisciplinary care teams. Teams at Ohio State University, part of the AAMC collaborative, are comprised of medical students, in addition to students in nursing, social work, pharmacy, medical dietetics, and public health. “Everybody is working together, bringing their particular profession’s expertise to the needs of the patient,” said Randy Wexler, MD, a professor of family medicine at the Ohio State University Wexner Medical Center, who leads the school’s hotspotting program.
According to Wexler, one Ohio State team showed a woman with several health issues how to keep track of her numerous follow-up appointments on a calendar, which helped her make it to more appointments. In another case, a pharmacy student organized medications and set up a reminder system for a patient who struggled to take her medications on time. “It’s high-touch, low-tech, but very labor intensive” he said.
“Everybody is working together, bringing their particular profession’s expertise to the needs of the patient.”
Randy Wexler, MD
Ohio State University Wexner Medical Center
Sale described how a team from the University of Rochester helped a woman with renal disease, who had been barred from every dialysis clinic in the community because she was unruly and yelled at staff. As a result, she was forced to go to the emergency department (ED) for treatment. When the team learned that she liked to draw, though, they brought her art supplies so she could calmly draw while receiving dialysis. She now has a successful relationship with a clinic, Sale said, which has improved her health significantly and reduced her hospitalizations.
Meeting patients where they are
Patients who visit the ED over and over often lack primary care, and may struggle with psychological issues or substance abuse. Some live in unhealthy housing or are homeless.
“One of our philosophies is ‘harm reduction’; to meet people where they are at that moment,” according to Brenner. “Some people are ready for different levels of medical treatment, addiction treatment, and behavioral health treatment.”
“We do a lot of patient-driven goal setting, so we really encourage patients to set goals,” Brenner said. “[Healthcare providers] tend do a lot of talking at patients and telling them what to do, but we [at the coalition] really try to elicit from patients what their goals are and think about how we can drive interventions based on those goals.”
The Camden Coalition recently received funding to create a national center for complex care that will bring together providers who work with complex patients. “[In the past,] we had not really come together [across disciplines] with clear frameworks for how to treat complicated patients and it’s clearly a multidisciplinary problem,” Brenner said. “So we think there is some real value to building a field and a movement specifically focused on patients who are medically, socially, and behaviorally complex.”