As a rule, health care systems are designed to work for the typical patient. Yet it’s well known that a small proportion of patients with complex, hard-to-manage needs and chronic conditions drives much of the cost in U.S. health care. So what’s being done to change this at the community level? One technique identifies these outliers individually, maps the constellation of problems they encounter, organizes resources around their needs and designs interventions to improve their care.
The approach, dubbed hotspotting, aims to fashion a system of multidisciplinary, coordinated care that in large part seeks to meet patient needs by addressing nonmedical issues that affect health. These include housing, mental health, substance abuse and emotional support. It isn’t a new concept, but it is being applied in new ways.
Beginning in 2014, the Association of American Medical Colleges (AAMC) joined with the Camden Coalition of Healthcare Providers and Primary Care Progress to launch the Interprofessional Student Hotspotting Learning Collaborative, in which participants learn from hotspotting pioneers how to identify and help patients who have multiple complex health conditions and use care frequently.
The 2016-2017 cohort features 31 teams of students at 27 schools across the country, including several member schools in the AMA’s Accelerating Change in Medical Education Consortium. The program also ims to broaden students’ understanding of their understanding of colleagues across professions.
Teams are comprised of students in medicine, nursing, pharmacy, dentistry, social work, public health, psychology, physician assistant, epidemiology, biomedical science, occupational therapy, health administration, medical dietetics, community health and business.
Each student’s work begins with identifying one patient who has been cared for in the inpatient setting three or more times in the previous six to nine months. Over the course of six months, the student follows 10 steps to gain insight into why the patient might be sick in the first place, determine why his or her condition hasn’t improved and then share these findings with health care system decision makers. As a student hotspotter, your tasks are to:
Step 1: Prepare a media and medical record release form. This will allow you to interview the patient and review their billing and medical records.
Step 2: Approach a care team member and ask that team member to contact you when someone who has been hospitalized three or more times over the last six to nine months is admitted again.
Step 3: Meet the patient and learn their story. Explain that you are trying to learn more about the challenges the patient faces in getting health care and that you would like to continue to meet after the patient is discharged. Ask them to sign the release form.
Step 4: Find out when the patient will be discharged as well as when any primary care or specialty care appointments are scheduled. Ask the patient for permission to meet him or her at those appointments.
Step 5: If the patient agrees, go to their home or shelter on the day they are released. Bring a fellow hotspotter with you. Get to know the patient’s personal history, interests and recent experiences seeking health care. The goal is to better understand the patient’s personal circumstances, which will then provide insights into their struggles with accessing needed care.
Step 6: Attend the patient’s follow-up medical appointments as an observer and find out what care looks like from their perspective. If the patient is eligible for any social services, accompany them in the application process so you can see firsthand what it’s like.
Step 7: Obtain a copy of the patient’s billing record and put together a summary showing how many times the patient has been admitted to the hospital in the past year and total the charges. Find someone in the billing office who can help you understand and graph the data.
Step 8: Prepare a case report of the interview and the patient’s medical history to shed light on why the patient has had to be hospitalized so many times. Share it with your colleagues and identify interventions that could improve the patient’s ability to access care outside of the hospital or emergency room.
Step 9: Put together a multidisciplinary team for a case conference. Determine how representative this patient is of patients with similar needs. Discuss what they have in common, where the health system fails them and what costs are incurred from their preventable care.
Step 10: Meet with the hospital CEO, the medical school dean and/or a faculty member. If the patient is willing to attend, bring them with you. Discuss the various implications of the patient’s experience, conclusions that can be drawn from their case and recommendations for improvements.
AAMC provides numerous hotspotting resources for students and faculty, including patient interview questions, sample medical record and media release forms, notes from the original cohort and more detailed descriptions of the 10 steps.