Collaborative care for the neediest patients is the focus of the new initiative, nationally and locally.
During graduate studies, many future health professionals are exposed to the impact of social determinants of health, and the external factors that can help or hinder individual and population outcomes and well-being. Some go further than that initial exposure and consider the burden of complex conditions and limited resources – both for high-need patients themselves and for the systems struggling to serve them across silos of care (inpatient, outpatient, mental health, and social services, for example).
Stuart Hammond, a University of Michigan graduate student in public health and public policy, didn’t just see the light on these issues – he gravitated toward it. He says that after eye-opening educational experiences coming to U-M from mid-Michigan suburbia, he got interested in global health. The more he learned about the U.S. health system, “the more I realized about the problems right here in our communities.” He was spurred to action after reading an Atul Gawande New Yorker article on how the U.S. could lower medical costs by “giving the neediest patients better care,” in the pioneering interprofessional “hotspotting” style of the New Jersey-based Camden Coalition of Healthcare Providers. Before long, Hammond succeeded in bringing the Camden Coalition “Student Hotspotting” initiative to U-M’s campus. It’s no coincidence that the “value of interdisciplinary collaboration” is listed as a primary learning outcome in the Camden model. Taking a patient-centered approach means taking care of the whole patient, including physical, emotional, and social needs.
Gawande’s article explains that health-care “hotspotting” got its name from data-driven techniques of “mapping crime and focusing resources on the hot spots.” The Camden Coalition’s student program trains interprofessional teams nationwide to work with “super-utilizers,” the small number of patients with hard-to-manage needs who end up accounting for a surprisingly high percentage of health care dollars. Camden Coalition cites Kaiser Family Foundation and 2014 data to make the claim of “5% of Americans accounting for nearly 50% of costs.”
At the core of the Camden model – more than a decade in the making–is the realization that heavy health care utilization for many patients is driven by more than physical disease. Complications like unstable housing, isolation, and other social challenges are often the root of the problem; they need to be addressed for medical interventions to be successful.
That’s where the student hotspotters enter. “Think about how well-informed family members might help someone with a mosaic of issues,” Hammond explains. “Hotspotting students aren’t providing care, but rather making connections to the services needed.”
U-M’s iteration of the Interprofessional Student Hotspotting Learning Collaborative, a program orchestrated by the Camden Coalition’s National Center for Complex Health and Social Needs, includes two teams made up of 10 students studying medicine, nursing, social work, law, and public health. The deans from each of the schools have contributed funds for the program, and faculty advisors from each school are in place.
Stuart Hammond is interested in policy and “lifting up patients’ stories to advocate for stronger social systems.”
During a summer 2017 data and consulting internship with the Camden Coalition, Hammond got a headstart with the agency’s approach to complex medical and social needs using a patient-centered approach. He now describes his role with fellow U-M hotspotting students as being “the glue that sticks the teams together, with no authority to tell students how to approach patients, and less clinical experience than most of the others.”
The student teams completed the first half of the Camden hotspotting training model online during fall semester of 2017 with preceptors, and at times with other students from across the country. Online modules addressed core skills like motivational interviewing, trauma-informed care, and harm reduction.
The second part of the hotspotting training model is experiential. Each interprofessional student team is expected to work with 3 to 4 local patients – and this is where Hammond and his fellow U-M hotspotters got lucky. When they went inquiring for patient connections in the Michigan Medicine system, a referral brought them in touch with Brent Williams, M.D., a U-M professor of internal and general medicine, member of the U-M Institute for Healthcare Policy and Innovation, and medical director of the U-M Complex Care Management Program (CCMP) since its inception in 2007.
Dr. Williams has years of experience with interprofessional education (IPE) and clinical care. The student hotspotting program resonated with him immediately: “I stepped in, called Stuart [Hammond] and suggested that he come see what we’re doing in our program.” Before long, Dr. Williams officially became the primary faculty advisor to the student hotspotter teams. The faculty advisors from the other U-M schools are Bradley Zebrack (social work), Michelle Pardee (nursing), Mary Janevic (public health), and Debra Chopp (law).
Dr. Williams helped the students negotiate administrative processes, and worked out how the student engagement with patients would work at Michigan. “It became a good idea for CCMP to play a brokering role,” he explains. “My contribution brought structures, with “bumpers” around such things as patient confidentiality and practice standards.”
Dr. Williams says the plan for the student hotspotters evolved in an interesting way. The easy thing would have been for the students to work with the patients enrolled at the clinic: the high-utilizers referred from other providers and granted CCMP case managers to help them navigate their discordant medical care.
“My contribution brought structures around such things as patient confidentiality and practice standards,” says Brent Williams, M.D.
“We originally thought the hotspotters would join [basically, shadow] a case manager, who would be ever-present at the side of students,” Dr. Williams explains. “But a different model emerged.”
The students will now work with needy patients referred to CCMP but not enrolled. These are patients limited by social challenges more than medical complexity, and thus outside of needing CCMP’s medical care management. Dr. Williams sees them as a group who could benefit greatly from being contacted by students.
So the patients who consent will get the students’ assistance navigating myriad issues and stressors around housing, transportation, food access, and more. “We at the clinic are the first triage, and the students can be somewhat autonomous, under the supervision of faculty advisors,” Dr. Williams explains. CCMP will be always ready as a resource, he adds.
“He’s brilliant with this,” Stuart Hammond says of Dr. Williams’ approach–both to complex care and the student hotspotters’ work. “We have an exciting opportunity to help by taking on the patients that CCMP wouldn’t otherwise be working with.” And the interprofessional student hotspotting teams will learn to work together, drawing upon their varied approaches and training across the different their disciplines, each offering a unique perspectives and strengths to benefit each patient.
The serendipity between Dr. Williams’ work and that of the hotspotters doesn’t end there. He is simultaneously working with an interdisciplinary faculty team as principal investigator on a U-M Interprofessional Exchange (IP-X) Research Stimulus pilot grant: “Caring for Complex Underserved Patients: Interprofessional Education and Care Where It Matters Most.” The purpose of the study is to bring interprofessional groups of health professions students to CCMP “to increase health professions learners’ knowledge, skills, positive attitudes, and career intentions related to care of complex patients.”
Dr. Williams sees himself as involved in both the hotspotting and the IP-X projects because he’s been doing clinical teamwork for more than a decade, and connects with others interested. The two efforts might inform each other as the hotspotting evolves, he acknowledges. One strong hope he has for interprofessional education (IPE), as stated in the IP-X project, is for the clinical experiences to be real meaning “add-in” to students’ clinical work, not just “add-on” in classrooms. He says he has seen an uptake of interest and activity around IPE at U-M lately, with much-needed inroads into the clinical sphere, as opposed to just didactic classroom IPE.
For his part, Hammond said he has been frustrated by a lack of “curricularized” IPE courses at U-M. “Interprofessional education is positioned as what you do on the side, only for people who really care about it. I think it should be more central. I go to occasional interprofessional events – but I am at capacity now, so it’s hard.”
He sees interprofessional education as “particularly applicable to the work of caring for complex patients, the underserved, and those often left out of health interventions.” As to his own professional future, he’s interested in policy and in “lifting up patients’ stories to advocate for stronger social systems. So maybe that means work at a nonprofit, in advocacy, empowering physicians by giving them tools and incentives. Or working toward better governance on the political side.”
Meanwhile, he believes student hotspotting “can push complex care forward.” To help with strategies around allocating and reallocating resources in health systems, he would love to have data informatics and computer science students on the teams.
“There’s a future role for IPE there, too.”
Student hotspotters nationwide. (Photo courtesy of Camden Coalition’s National Center for Complex Health and Social Needs)