Identifying and Engaging High-Risk Patients Through Hotspotting

The innovative strategy of hotspotting, implemented by the Camden Coalition of Healthcare Providers, was the focus of a session and a panel discussion during the first day of the ACO & Emerging Healthcare Coalition in Philadelphia, Pennsylvania.

Patients who have serious medical conditions and social complexities pose a significant difficulty for healthcare systems, as they often end up in emergency departments (EDs) too frequently. The Camden Coalition wants to change that by identifying these high-risk patients and empowering them to improve their health, said Natasha Dravid, MBA, associate director for business planning and continuous improvement for the Camden-based ACO.

During Dravid’s presentation, she outlined the work of the Coalition, which includes a Care Management Initiative that targets the top 1% of the most complex patients, but mainly focused on the newer 7-Day Pledge initiative, which targets patients who have been discharged from inpatient care or who have visited the ED 5 or more times in 6 months. Both programs use the principle of hotspotting, which is “the strategic use of data to target evidence-based services to complex patients with high utilization.”

The 7-Day Pledge, Dravid said, relies on the cooperation of primary care physicians in the attempt to get every patient in for a follow-up appointment within 7 days of discharge. Dravid emphasized that cooperation is key to achieving this 7-day goal, which would be impossible without practice buy-in. Before the program’s launch, the Coalition team held conversations with every practice and heard feedback that the providers were feeling overburdened and not compensated enough. The Coalition agreed it would be difficult to convince these overworked physicians to take on the challenge of the 7-Day Pledge.

“We really needed to acknowledge that we were asking extra,” Dravid said. In response, they created a reimbursement program that pays both providers, who get financial bonuses for each timely follow-up, and patients, who receive gift cards and taxi transportation to and from the appointments.

The program has seen encouraging results, with the rate of patients being seen in a primary care appointment 7 days after discharge rising from 26% in February 2015 to 42% in December. Dravid said that although they still did not have enough outcome data to draw conclusions, the Coalition team members had seen a real difference in the attitudes of the community and its healthcare providers.

“It gave us the mechanism to celebrate as a city, that’s a rare thing in Camden,” she said of the program’s progress. By being able to watch the changes in follow-up rates, providers “were able to think for the first time that something in Camden was changing, and they were part of that change.”

A panel discussion then followed, in which Dravid discussed the program’s implications with Cary Sennett, MD, PhD, FACP, president and CEO of the Asthma and Allergy Foundation of America, and Frank Urbano, MD, MA, senior medical director of AmeriHealth New Jersey. The panelists agreed that the feeling of recognition and accomplishment can be more important for the participating physicians than the financial reimbursement.

“Sometimes just listening to them is a more powerful incentive than giving them a check,” Urbano summarized after a discussion of the different motivations that can drive people.

The panelists also discussed the importance of examining the broader picture of a patient’s life and neighborhood, not just their disease state, with Sennett using the example of housing code violations, like cockroaches and mold, in socioeconomically depressed areas causing high rates of hospital admissions for asthma.

Stakeholders need to ask themselves “a profound and important question,” Sennett concluded. “What does it take to improve the health of a population? What are the roles and opportunities and responsibilities of those who are committed to doing that?”