Hotspotting: Care Intervention for the Most Complex, Costly Patients

During the first day of the ACO & Emerging Healthcare Delivery Coalition, speakers from the Camden Coalition of Healthcare Providers outlined an intervention that works with the 1% most complex and costly patients in Camden, NJ.

Renee Murray, associate clinical director of Care Management Initiatives at Camden Coalition, and Andrew Katz, senior program manager of Care Management Initiatives at Camden Coalition, began with a patient profile: George, who was diagnosed with schizophrenia, newly diagnosed with diabetes, had a cognitive delay, and minimal social support and interaction. He lands in the hospital 24 days a year, which reduces his quality of life, and during his most recent hospital admission, a team from the Camden Coalition met him at the bedside to develop a relationship and begin to help him meet his health goals.

Camden Coalition utilizes hotspotting, which segments patients on complexity, rather than disease type.

"In the traditional paradigm, we will often segment patients based on the conditions they have," Katz said. But there are patients within the segment that have their disease well controlled, but others that do not. He added that patients on the extreme end often have more in common with patients with diseases in other segments than patients with the same disease as them. Plus, patients can fall into multiple buckets, which hotspotting takes into account.

Camden Coalition detects patients based on their hospital utilization and review their charts to identify those who also have social complexity, such as transportation issues and unstable housing.

Through the use of 3 teams—community team, hospital team, and social work team—Camden Coalition meets patients at the bedside when they are admitted to the hospital, meets patients in the community at their home, and ensures that patients follow their discharge plans, take their medications, and get connected with a primary care provider.

When the team meets with the patient, they go over the domains of care that are important to the patient, most of which aren’t even related to medical care, Murray explained, because social complexities really go “hand in hand” with health.

For instance, a team might accompany patients to the board of social services for temporary rental assistance, to the DMV for a driver’s license, or even to court, if necessary.

“Wherever the patient identifies that they need a little more support or a little more coaching,” Murray said. The plan is to empower the patient to continue doing those things on his or her own without the team.

In the case of George, when the community team met him at his house after discharge from the hospital, they discovered he didn’t know how to properly draw insulin, had medications scattered throughout the house without any organization, and was unable to take his schizophrenia medicine because the hospital mistakenly believed his mother could administer it (the Camden Coalition community team discovered his mother was elderly and bedridden).

“This is not safe,” Murray recalled thinking when she saw his situation, “and we have a lot of work to do here.”

Ultimately, Camden Coalition was able to get George’s primary care provider to take ownership of his schizophrenia medication and administer it to him, teach him how to properly draw his insulin, and get him involved with a program that had him socializing with peers.

The intervention program is usually between 90 to 120 days, and once the patients finish the program and are ready to take control of their care, the Camden Coalition presents them with a certificate. It may only be a piece of paper in a frame, but it can be really important to the patient, Murray said.

“For the patients, sometimes it’s the first time in their lives that they’ve received anything that says they’ve accomplished something,” Murray said.