Background
In 2016, healthcare made up 17.9% of the U.S. GDP, and is expected to rise to 19.7% by 2026 (1, 2). The government will be expected to pay almost half of these costs; that is to say government-sponsored share of health spending is projected to account for 47% of national health expenditures by 2026 (2). Healthcare costs are driven largely by a group of high-need, high-cost patients called High-Utilizers who constitute 5% of the population but account for about 50% of health care expenditures (3). The need for intensive healthcare resources for high-utilizers is often short, as fewer than half remain in the top 5% for more than seven months (4).
Hotspotting is an intervention that addresses many needs of High-Utilizers and significantly reduces both hospitalizations and overall mortality (5). From the Atlanta-based program, we present a robust and reproducible intervention called Healthcare Hotspotting to engage interdisciplinary graduate and professional students in delivering integrated, person-centered care for patients with complex health and social needs. Interprofessional education for healthcare workers has been cited by many entities including the National League for Nursing, National Academy of Medicine (formerly IOM), and World Health Organization as pivotal to creating safe, affordable, and enjoyable healthcare facilities (6).
Methods and Measures
One team of 3-5 interprofessional students coordinates care for up to five High-Utilizers during the six month intervention. Given the limited sample size of patients per team, most analysis will be concentrated on using descriptive statistics. With more data available over time, we will iteratively expand our data metrics. Metrics will measure Patient Outcomes, Student Learning, and Costs to Grady. Values at 6 and 12 months will be compared to the baseline values
Inclusion criteria for patients includes: at least 3 inpatient admissions in the last year, 2 or more decompensated chronic diseases (may include mental health diagnoses), and age 18 or older.
Exclusion criteria for patients includes: life expectancy < 6 months, no reliable way to communicate with the patient (no phone, no email, etc.), and history of abuse towards care teams.
Intervention
The Atlanta-based interprofessional student hotspotting learning collaborative was brought to Atlanta in 2017 through the partnership of student leaders from three schools: Emory School of Nursing, Emory School of Medicine, and Georgia State University School of Social Work. Atlanta’s student hotspotting team is part of an annual program established in 2015 that trains interdisciplinary teams of professional students from schools around the country. The national program is arranged by the Camden Coalition of Healthcare Providers, and hosted by the Association of American Medical Colleges, Primary Care Progress, National Academies of Practice, Council on Social Work Education, and American Association of Colleges of Nursing. The national hotspotting program has participants from over twenty different universities, and includes students studying nursing, medicine, social work, public health, law, and pharmacy. During the 2017-2018 school year, a pilot interprofessional student hotspotting team in Atlanta set roots.
One of the main tenants of the program is that students learn by doing. In their respective communities, student hotspotters provide support to high-utilizers in navigating personal and systemic barriers that contribute to over-utilization. Hotspotters do not provide medical care or advice. By working alongside patients to navigate roadblocks to efficient and effective outpatient management, student hotspotters learn not only about the unique challenges experienced by these patients but also the efforts required to address them. In doing so, student hotspotters gain valuable training that enables them to be more compassionate, collaborative, effective, and comprehensive healthcare professionals.
In addition to learning by working with high-utilizers, student hotspotters will also participate in a national curriculum arranged by the Camden Coalition of Healthcare Providers. The curriculum includes video training modules, with topics including motivational interviewing, trauma informed care, and harm reduction. In addition to the training modules, students will also participate in case conferences with other interprofessional student hotspotters completing the intervention in other cities.
Results
The 2017-2018 Atlanta pilot team consisted of students and faculty mentors from the Schools of Nursing, Medicine, and Social Work from Emory and Georgia State Universities. During the pilot year, the Atlanta hotspotting team established administrative structures at Emory University School of Nursing, Emory University School of Medicine, Georgia State University School of Social Work, and Grady Memorial Hospital.
Establishing the structure within the schools included finding faculty mentors, meeting with faculty governing interprofessional education (IPE), designing recruitment strategies for interested students, receiving IRB exemption status, and receiving safety clearance as well as extension of student liability insurance. Within their respective schools, student hotspotters also outreached to peers to build interest in the program. Outside of their schools, student hotspotters have contacted law, business, pharmacy, and public health students and faculty from universities in the Atlanta area to expand the interprofessional nature of future teams.
At Grady Memorial Hospital, establishing the program included partnering with the Director of Population Health, receiving entry to the Chronic Care Clinic, and meeting with Chronic Care Clinic staff to articulate an interventional framework that is mutually beneficial for high-utilizers, clinic staff, and student hotspotters.
The pilot team also consulted with the Georgia Clinical and Translational Science Alliance Biostatistics, Epidemiology, and Research Design service to create data capture and evaluation techniques.
Next Steps
One immediate goal of the Atlanta hotspotting team is to establish three interprofessional student hotspotting teams for 2018-2019 school year. The three teams will coordinate care for 15 High-Utilizers through regular home visits, close relationships, guidance through hospitals, state and non-profit agencies. We also hope in the next year to increase social work, law, and pharmacy student presence by connecting to faculty and student leaders at respective schools in the Atlanta area.
An eventual goal of the Atlanta interprofessional student hotspotting learning collaborative is to incorporate the program into curricula within health professions schools. Schools of nursing, medicine, and social work all expect students to engage in interprofessional education and hands-on community service. We believe our program can meet curricular requirements for students to receive credit for participation, and have begun conversations with administrators at each of the schools about participation for academic credit.
Funding
- Emory University Nell Hodgson Woodruff School of Nursing Dean’s Fund
- Emory University Primary Care Consortium
- Emory-Georgia Tech Healthcare Innovation Program/Georgia CTSA Seed Grant
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