Strategic Hot Spotting
The continued rise of health care costs in the United States (US) calls for strategic action. A huge push is to reduce hospital readmissions for groups of patients such as those with diabetes, chronic obstructed pulmonary disease (COPD) and chronic heart failure (CFH). Tailored efforts are placed in reducing overall readmission rates of these populations to include succinct care plan methods. According to Dr. Brenner, founder of the Camden Coalition of Healthcare Providers (CCHP) healthcare hot spotting is a borrowed concept taken from William Bratton’s New York City police reform (n.d.). The police reform shifted gears to focus on the small number of people committing crimes to reduce the overall crime rate in New York City (NYC). Dr. Brenner discusses the same analogy in healthcare where high utilizer patients drive up health care costs (CCHP, n.d.).
Health care hot spotting focuses efforts on the high utilizer patients to reduce their number of hospitalizations and resources. In essence, identifying high utilizers allows for focused efforts of care. This can drive down the cost of care as future admissions and hospital visits are decreased. In fact, 50% of healthcare spending is related to the top 5% high utilizers (Lagasse, n.d.). The cost of care for high utilizers can be further broken down to show cost per system. For instance, the cost for cardiovascular care for the 5% high utilizer group was $74.1 billion dollars, accounting for 73.4% of the total spending on heart disease in 2012 (Martinez, King, & Cauchi, 2016).
Strategic Hot Spotting Case Review
Prior to the creation of the CCHP, Dr. Benner’s work focused on patients who received bad health care in Camden, NJ. In an article by Gawande (2011), Dr. Benner focuses on specific patient’s who are in and out of the hospital frequently, resulting in huge costs and resources to the health care system. To understand an 800-patient study, a single patient case will be examined to provide specific content.
Dr. Benner’s first patient is a gentleman in his forties with comorbidities such as morbid obesity, CHF, chronic asthma, and a history of smoking and alcohol use (Gawande, 2011). The typical methodology for treating this patient who is in and out of the hospital includes education, prescriptions on discharge and follow-up appointments. Dr. Benner took this to a whole new level. From simple education tactics and motivation to ongoing home checks, this patient was able to lose weight, stop drinking, and even began cooking his own meals. This type of commitment by a physician helped reduce overall hospital visits from a single patient. This raises the question whether increased resource and commitment to a single high utilizer patient result in lower costs and resources.
In a randomized-controlled trial, 800 complex patients were monitored based on traditional care or care identified as Camden Coalition Care (Finkelstein, Zhou, Taubman, & Doyle, 2020).Understanding if a Camden coalition to care approach favors the traditional care approach is measured in terms of readmission data. This study benchmarked 180-day post discharge readmission rates for both groups. Results for the control group showed a 61.7% readmission rate and 62.3% for the control group (Finkelstein, Zhou, Taubman, & Doyle, 2020). Although there is no significant different in this trial, it is important to examine the Camden Coalition Care approach. The fact of the matter is the coalition seeks out the high super-utilizer patients who have medical and socially complexities. The study indicates limitations such as patient relationships with providers and other non-tangible benefits, while comparing outcomes with programs with less complex patients (Finkelstein, Zhou, Taubman, & Doyle, 2020). In the Camden Coalition case, a high utilizer falling out of the readmission rate is more impactful than patients who are not high utilizer. The research data shows no real change in readmission rates.
The focus and recommendation to senior leaders is based on the overall cost savings and impact improving medical and social issues for a single high utilizer can have on an organization.
Strategic Recommendations to the CEO
Rural medicine brings unique challenges in terms of access to care, resource availability, and primary care support. Efforts to reduce hospital costs while increasing profitable volumes is necessary to ensure a healthy bottom line. Strategies to reduce hospital readmissions tend to focus on groups of patients, such as heart failure, diabetes, and chronic pulmonary disease. Value is delivered when patient’s in these groups visit the hospital less. Following the strategy of the Camden Coalition Care model offers value to high utilizer patients and the staff who are for them. Health care providers who care for high utilizer patient’s often feel their time, work, and efforts are meaningless when the patient comes back to the hospital days later. Benchmarking the top 5% as identified in the literature helps in strategizing the percentage of patients for focused interventions.
The goal of this segment includes strategic recommendations to the Chief Executive Officer (CEO) on a rural hospital on ways to reduce costs and improve patient and staff satisfaction. Since the hospital has strong competition 10 miles to the south as well as clinics setting up in their back yard, efforts to reduce high utilizers provides competitive advantage. A key ingredient in achieving competitive advantage includes providing resources that are rare, difficult to reproduce, and valuable to external stakeholders (Ginter, Swayne, & Duncan, 2018).
How does a rural hospital sustain a competitive advantage with all the challenges they face? Recommendations to the CEO involve the following interventions necessary to identify high utilizer patients and provide strategic, collaborative plans of care:
• Informatics team to create report pulling data from the electronic medical record (EMR) to identify patients with more than one hospital visit
• EMR report isolates top 5% patients and submits list to case management director and manager
• Each patient in the 5% group will be assigned a hospitalist provider and case manager for weekly follow up via on site meetings, telehealth visits and/or home visits.
• Monthly progress meetings with hospitalist and case management team with ad-hoc communications with patient’s primary care provider and other outpatient service providers.
• The team will connect patients to services such as: meal services, transportation services, support groups such as weight loss and alcoholics anonymous.
It is well documented in the literature that high utilizer patients require much more than a physician and case manager “looking after them”. Patient care needs include: a primary care physician, social services, food and meal services, and even legal support (Burns, 2020). Recognizing this is a challenge for rural hospitals facing their own financial struggles. It is recommended that the hospital builds partnerships with community resources to help put more eyes on high utilizer patients. Additional recommendations to the CEO and hospital executives revolves around the management of patient’s visiting the emergency department (ED).
Why People Visit the Emergency Department
Many theories exist and evolve around the question, why do people visit the ED? We can instantly remove the immediate answer to set-aside those who have actual emergencies such as horrific traumas, heart-attacks, strokes, and other serious situations that require immediate medical attention. The literature suggests the highest use of ED visits deemed as non-urgent is due to chronic pain followed by chronic disease management and psychological crisis (Kang-Lim, 2015). There are two lanes in understanding why people select the ED. The first lane is access to primary care. For this reason, many ED’s across the country are used as primary care providers to deal with routine care physicals needed for school and work, prescription refills, and general aches and pains. The second lane is how people perceive the urgency of their own situation. In a study involving 417 patients and eight public hospitals in Australia, 48% felt they were much sicker than the initial triage score they received in the ED (Toloo, Aitken, Crilly, & FitzGerald). It is logical to assume that after an ED visit that was not considered urgent the patient may assume a different avenue when facing similar symptoms in the future. Any ED nurse or doctor can tell you this is not always the case. Patient’s in both lanes are more likely to result in high utilizers. This ED use can overflow into admissions with poor discharge planning, creating a vicious cycle. Recommendations for the CEO to help reduce costs, free up precious resources, and avoid quality penalties include, having a strategy for high utilizers in the ED. After all, this is the portal of entry into the hospital. A study involving 99 high ED utilizers, 22 of the 33 patients who received a referral intervention during their ED visit did not re-visit the ED within the six-month post-monitoring period (Kang-Lim, 2015). Based on this study the following recommendation for the CEO includes:
• ED physician to patient consult on importance of having a primary care provider (PCP)
• Brochures for local mental health support clinics, providers, and networks
• Written referral to PCP or mental health provider prior to ED discharge (Kang-Lim, 2015).
• Assignment of consistent case manager in ED with call-back within 72-hours of discharge.
• EMR flag for high utilizers to avoid immediate admission. This included services and community contacts to coordinate discharge from ED.
Community Issues: Short and Long Term
As Camden’s crime increased to a level of complacency, the city needed a new approach. Serving as one of two community citizens on a police reform commission, Dr. Brenner was introduced to the idea of mapping crime rates (Gawande, 2011). Dr. Brenner’s theories were turned down in creating policing maps, however the data identified spots associated with multiple people going to the hospital. Communities like Camden lack the appropriate resources in the right places. Community issues result in both short term and long-term problems related to health care. Short term issues such as not enough secondary care facilities post discharge can result in rehospitalizations. Communities with few primary care providers experience short term struggles for routine care and wellness. A lack of resources to help challenging populations with weight control, smoking cessation, and diabetes management results in sustained long-term chronic illnesses. Windshield surveys help identify community risk factors such as the number of fast-food restaurants, liquor stores, and churches n support centers. Addressing community issues requires an understanding of the residual impact inadequacies can have on communities. One study shows that investing in nurses and social workers to partner high utilizer patients with resources such as housing, transportation, and meal services resulted in a savings of $9 million that would have been spent on repeat ED visits (Almendrala & Galewitz, 2020). Unfortunately, improving community issues alone is not always enough to make the big improvements necessary to move the dial. This signifies the critical need for hospitals to have strong community presence and help influence what resources are established within communities.
Monitoring and Tracking Complex Populations
The ideal situation for every patient in every community easily looks like this: patient is discharged, data is collected, and shared, out-patient agencies provide resources and shared results, and patient outcomes are documented and shared. If all hospitals, clinics, primary care offices, and community health services collected, tracked, and shared data, monitoring, and tracking complex populations would be simple. Coordinating care to target high utilizers would become a proactive approach rather than a reactive goal. Studies show that health care lags in integrating data analytics into their own daily operations (Harris, 2018). Failure to buy-in to the importance of data and analytics results in poor patient tracking and monitoring. In fact, one study showed that as many as 56% of hospitals lack any strategy for data analytics (Harris, 2018). The struggle goes beyond the hospital having a strategy. All health care entities must have a system for tracking, trending, and monitoring complex populations plus have a way of sharing data between organizations. With multiple systems and methods for collecting data, sharing, and acting on relevant data is difficult. Context to the problem is as simple as when a primary care office is unaware their chronically ill patient has been hospitalized for one week. The home health nurse received a faxed report and plans on checking in after discharge. The patient is sent to a rehabilitation center out of town due to lack of beds. The patient is now followed in a new community by a new social worker. Coordination of care for complex populations requires and depends on inter-professional relationships.
Inter-Professional Relationships
Professional curtesy and caring results in closed loop communication necessary to provide good care to high utilizer patients. As Dr. Brenner relates, these are the patients ultimately receiving bad care. Relationships between physicians is critical for good patient care to happen. Physicians may dictate a report and carbon copy to the patient’s primary care provider and move on to the next case. This is where and how patient’s fall thru the cracks. Physicians need to have actual conversations and share ideas, establish goals, and hold one another accountable for their immediate actions and responses to their patients. Inter=professional relationships between disciplines require trust and must lack the hierarchal prestige often associated within the ranks. Meaning, physicians need not be too good to call the social worker or public health nurse to share concerns and goals for their patients. Physicians must allow all disciplines to help coordinate and share concerns for patients, along with recommendations. In the hospital multi-disciplinary rounds (MDR) provides a platform for coordinated care between all disciplines to establish a solid discharge plan. This coordination must extend to the community providers to provide congruency of efforts. In conclusion, using informational technology and all the tools at our disposal, allows us to identify those patients that if efforts are applied in great force, results in cost savings and a reduction in hospital resources. This is much easier said than down, however simple steps to identify and begin adding extra efforts to these patients is a start. Increased efforts to coordinate, follow up, visit, and plan the care for those who are often dubbed as “frequent flyers” in the hospital world can help both the patients and staff feel they are valuable. Improving a single patient’s overall care allows for the patient to give back to the community while offering more resources to other community members. This is a cycle when done consistently can have huge impacts on whole communities.
References
Almendrala, A., & Galewitz, P. (2020, Jan 24). Despite new doubts, ‘Hotspotting’ help for heavy health care users marches on. Lnp Retrieved from http://library.capella.edu/login?qurl=https%3A%2F%2Fwww.proquest.com%2Fdocview%2F2344542529%3Faccountid%3D27965
Burns, J. (2020). Camden coalition finds new ways to care for high utilizers. Managed Healthcare Executive, 30(8), 32-34. Retrieved from http://library.capella.edu/login?qurl=https%3A%2F%2Fwww.proquest.com%2Fdocview%2F2440493530%3Faccountid%3D27965
Camden Coalition of Healthcare Providers. (n.d.). Healthcare hot spotting. Retrieved from https://hotspotting.camdenhealth.org/
Finkelstein, F., Zhou, A., Taubman, S., & Doyle, J. (2020). Healthcare hotspotting – A randomized controlled trial. New England Journal of Medicine, 382(2), 152-162. doi: 10.1056/NEJMsa1906848
Gawande, A. (2011). The hot spotters. Retrieved from https://www.newyorker.com/magazine/2011/01/24/the-hot-spotters
Ginter, P. M., Swayne, L. E., Duncan, W. J. (2018). The strategic management of healthcare organizations (8th ed.). Hoboken, NJ: Wiley Publishing
Harris, J. (2018). The opportunities and challenges in data analytics in health care. Retrieved from https://www.brookings.edu/research/the-opportunities-and-challenges-of-data-analytics-in-health-care/
Kang-Lim, T. (2015). Emergency department: Effectiveness of a referral intervention for high utilizers. Retrieved from http://library.capella.edu/login?qurl=https%3A%2F%2Fwww.proquest.com%2Fdocview%2F1691751480%3Faccountid%3D27965
Lagasse, J. (n.d.). ‘Hotspotting’ in healthcare has little to no effect on patient outcomes. Retrieved from https://www.healthcarefinancenews.com/news/hotspotting-healthcare-has-little-no-effect-patient-outcomes
Martinez, J. C., King, M. P., & Cauchi, R. (2016). Improving the healthcare system: Seven state strategies. Retrieved from https://www.ncsl.org/Portals/1/Documents/Health/ImprovingHealthSystemsBrief16.pdf
Toloo, G. S., Aitken, P., Crilly, J., & Fitzgerald, G. (2016). Agreement between triage category and patient’s perception of priority in emergency departments. Scandinavian Journal of Trauma, Resuscitation, and emergency medicine, 24(126). doi: 10.1186/s13049-016-0316-2