Creating the Next Generation of Hot Spotters
This guide focuses on identifying just one patient who has been cared for in the inpatient setting three times or more over the past six to nine months. These ten steps will provide a simple but powerful way for you to connect with the patient, get to know him or her as a person, and see what you can learn and what you can change. Start today. Follow these ten steps. Become a hot spotter.
Step 1: With help from your legal department, prepare a media and medical record release form that will allow you to interview the patient and review their old billing and medical records.
Step 2: Approach a social worker, hospitalist, attending, discharge planner, nurse, or other care team member and ask that person to page or text you when someone who has been in the hospital multiple times (three or more) over the past six to nine months is admitted again.
Step 3: Meet the patient at his or her bedside and begin to learn this person’s story. Introduce yourself and explain that you are trying to learn more about the challenges patients face getting health care. Explain that you would like to get to know him or her, talk with the person during the hospital stay, continue to meet after discharge, and view his or her hospital records. If the patient agrees, ask him or her to sign the release form. If willing, you may also ask the patient if he or she would consent to being audio or videotaped for a wider audience, and if so, obtain an additional signature.
Step 4: Coordinate with the discharge planner so you know when the patient will be discharged as well as when any follow-up appointments with a primary care physician and/or specialist are scheduled. Seek permission from the patient to meet him or her at follow-up appointments.
Step 5: Go to the patient’s home, shelter or other residence on the day he or she is released if the patient agrees. If the patient consented, take a digital recorder or flip cam and record the interview. Don’t go alone, bring a fellow “hot spotter” with you. (This could be another student, a social worker, community health worker, or other colleague who wants to learn more about how to improve care for complex patients.) Find out who this patient is, his/her likes and interests, where he or she grew up, as well as learning about his or her recent experiences seeking health care. The goal is not to get a medical history but rather to better understand the patient’s personal circumstances, which will provide insights into this person’s struggles with getting care in an outpatient setting.
Step 6: Go with the patient to any follow-up medical appointments as an observer and find out what health care looks like from the patient perspective. If the patient is eligible to apply for any social services, go with him or her so you can see firsthand what that process is like.
Step 7: Obtain a copy of the patient’s billing record from the hospital and put together a summary that shows how many times the patient has been admitted to the hospital or emergency room in the past year and the total charges for the patient. Find someone in the billing office who can help you understand the data and put together a summary using excel graphs and tables.
Step 8: Prepare a case report of the interview and medical history that sheds light on your understanding of why the patient has had to be hospitalized so many times and share it with your colleagues. Identify potential interventions that might improve the patient’s ability to access needed care and services outside the hospital or emergency room.
Step 9: Assemble a multidisciplinary team of physicians, nurses, social workers, quality improvement experts, and other health professionals for a case conference. Enlist the support of a faculty member, if needed. Discuss the case, refine interventions and explore how representative this patient is of other patients with similar needs. What do these patients have in common? Where does our health system fail them? What costs are incurred because of preventable care for these populations?
Step 10: Meet with the hospital CEO, medical school dean and/or faculty member to discuss the clinical, educational and financial implications of this one patient’s story. If the patient is willing, bring him or her with you. What conclusions do you draw from this case, and what recommendations do you have for improvements?
Patient Interview Questions
Sit next to the patient at the bedside, and make eye contact. You may consider removing your white coat beforehand in order to help the patient feel comfortable opening up to you. Briefly introduce yourself and explain that you are interested in helping patients get better care. Ask the patient if he or she would mind if you ask a few questions to get to know him or her better.
If the patient does not want to talk to you, respect his or her decision. Ask if the patient would like you to come back if he or she is admitted to the hospital again. It may take some time for the patient to want to open up, and this step shows that you are committed to helping the patient on his or her own terms.
If the patient is willing to talk, here are some sample questions to help you get started. Be prepared with follow-up questions if you initially get short responses. It may take time to draw out the patient. Work more on forming a connection with the patient and getting to know him or her, rather than following a rigid script.
What’s your name?
Do you live nearby?
Where did you grow up? (Possible follow-ups: What did you like about growing up there? What did you dislike? Why? Are you still close with friends from those days?)
What are some of the things you enjoy doing? (Possible follow-ups: How often do you get to do that these days? What would make it easier for you to do this more often? What is your best memory of doing that? What do you usually do on weekends?)
Can you tell me a little about how you ended up in the hospital? (Let the patient tell his or her story. Allow the patient to talk for as long as he or she wishes.) (Possible follow-ups: What time of day was it? Were you alone or was someone there with you? Who took you here or called the ambulance? Was there anything different about this trip from other trips to the hospital?)
I noticed you’ve been in the hospital a lot lately. Would you like to talk about what else is going on with your health? (Possible follow-ups: Who do you currently talk to about your health? How do you get there? Do you feel like they understand you? Do they listen to you?)
Can you tell me about some of your good and bad experiences with the health care system? (Possible follow-up: What could have made that experience (even) better?)
Do you have any problems getting the care you need? Can you share with me some of these problems? (Possible prompts: What was it like getting to the appointment? Did you have to wait long? Reschedule? Do you have any co-pays? Not sure who you should see? Difficulty getting the medicines you need? )
Do you have a primary care physician? In other words, do you have a regular doctor who you can call or see when you are having less urgent health problems but don’t know what to do? (Possible follow-ups: Does what he/she prescribes to you make sense or seem like something you can do? Why or why not? What would you like the doctor to know or think about that you haven’t already discussed with him/her? Do you feel like that is something you could tell your doctor?)
Are there other members of your family or the community who check in on you, or to whom you can turn when you aren’t feeling well? What about social workers, case managers, or other members of your health care team? Would you mind if I contacted some of them to talk about ways to help you together? If family members are present, you may want to include them in the conversation as well. They can provide additional clues about the patient’s experience, background, and barriers to care.