Hotspotting gives med students insight on vulnerable patients

Brendan Murphy , Senior News Writer

A student-driven program at the University of North Carolina (UNC) is aiming to cut health care costs and improve the quality of care provided to some of the most vulnerable patients, and it is using compassion as a primary tool to help accomplish those objectives.

The Triangle Interprofessional Partners for Prevention—which follows the lead of the “hotspotting” initiatives undertaken by the Camden Coalition over the past two decades—works to identify high-utilization patients, determine barriers to their health and reduce them. The legwork is done by interprofessional teams of UNC students from across a handful of health care disciplines.

Faculty members from UNC presented the project at the recent AMA ChangeMedEd® 2017 national conference. Amy Weil, MD, the director of interprofessional education at the UNC School of Medicine, oversees the program.

“This is the idea of service and learning,” Dr. Weil said. “You can get people who are entering into the health care profession—who are eager and not burned out—to go and listen with their minds and hearts to find out ‘what’s the thing that’s preventing you from getting better.’ Sometimes those things are very simple and they are not even really biomedical.”

In the U.S., 5 percent of the patient population accounts for 50 percent of health care expenditures, according to an August 2013 Agency for Healthcare Research and Quality statistical brief. In some instances, those patients do not present with conditions that should require extended hospital stays, but because of external—often social—factors, they do.

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UNC’s program defines a high utilizer as a patient who has had three or more hospitalizations, takes five or more medicines and does not carry  an extreme diagnosis such as cancer or the need for surgery that would necessitate repeat hospitalizations. Once those patients are identified, the goal then becomes finding the contextual challenges that may be interfering with their health. Students do that by visiting patients in their homes and establishing patient-centered goals about their health.

The Triangle Interprofessional Partners for Prevention began in 2014. It was buoyed by a small grant from the famed Camden Coalition, which is led by Jeffrey Brenner, MD, a pioneer of using data to identify and improve the care for high-need, high-cost patients.

The pinnacle patient that year was a man who had been frequently hospitalized, sometimes for months at a time, with Crohn’s disease and diabetes, a condition for which prolonged hospital stays are rare. The man did not have teeth, a factor that contributed significantly to his poor eating habits, exacerbating his conditions. When that was identified, students worked on his behalf with several stakeholders to secure funding for dentures.

“The moment he had dentures, he could eat properly and he was no longer hospitalized for the problems that were keeping him in the hospital,” Dr. Weil said. “It’s the stuff that falls through the cracks. Because without an advocate he had no way of figuring out how he was going to get the dentures.”

UNC’s hotspotting program has about 20 students from several different areas of focus. Five of them are medical students, with others studying to become social workers, nurses, pharmacists, physician assistants or as public health professionals.

Students entering the program are trained by a group of faculty members from different professions. Once the training concludes, students conduct home visits in small interprofessional teams. They then report back to the larger group for input and ideas.

The value of working with students from across the spectrum of health care, Dr. Weil believes, is significant.

“It’s obvious to me that working with people from other professions is not just a nice idea,” she said. “It’s what [physicians] do every day. This is an opportunity for [students] to understand what each of them brings to a patient.”

In speaking with patients during home visits and while navigating on their behalf in a clinical setting, students aren’t necessarily honing their clinical skills. But that does not mean that they cannot be a driving force toward a solution. Helping to fill out paperwork or getting a patient transportation to receive care can go a long way.

A majority of the students in the Triangle Interprofessional Partners for Prevention do so on a volunteer basis, meaning they do not receive class credit. (Dr. Weil is working to change that.) In spite of that, she believes they are getting a valuable lesson in compassion.

“You are right there with a human being who you can see is suffering,” Dr. Weil said. “These people really need help that they are not getting from our traditional health care system, and students really need to learn lessons about what makes people vulnerable and that they can do something to help those people get better.”

The presentation on North Carolina’s hot-spotting program was among dozens that took place during the ChangeMedEd conference. The event showcased how the AMA, through its Accelerating Change in Medical Education initiative, is working to reimagine and shape the future of medical education.