Interprofessional Education Hotspotting A CommunityBased Approach for Addressing

Interprofessional Education Hotspotting: A Community-Based Approach for Addressing Health and Health Care Utilization of Valuable Older Adults Susan Hall, DNP, APRN, WHNP Cassie Kuhn, BSN, DNP Student April 2018

Objectives • Describe Hotspotting as a method for intervening with patients who have highly complex needs. • Consider approaches for using Values-Driven Outcomes Data to identify individuals who may benefit from a Hotspotting intervention. • Identify appropriate educational outcomes for Interprofessional Education (IPE) teams participating in an IPE Hotspotting Immersion. • Describe the processes and challenges of creating and implementing IPE Hotspotting teams • Discuss the benefits of successful Hotspotting for patients, health professions students, and health care delivery systems. • Discuss student and participant experiences working with a Hotspotting team

Project Goals Develop a rigorous and sustainable IPE Hotspotting Immersion: 1. building IPE Competencies with knowledge and skills for effective systems-based practice 2. addressing drivers of health and healthcare utilization for vulnerable populations in our community 3. improving health and wellness of individuals with highly complex needs 4. reducing total costs of care for high utilizers of health care

Background • Hotspotting refers to collaborative work of interprofessional teams seeking to use local data to gain insight and intervene in the root causes of high healthcare utilization and poor health outcomes for selected patients and populations. • The Housing First Model provides chronically homeless individuals with permanent supportive housing, and voluntary, flexible, wrap-around social services, substance abuse treatment, education, and employment.

Participants • Students from Public Health, Medicine, Nursing, Social Work, and Pharmacy • Residents/clients – Housing First Residents who were older – Several clients who utilize University of Utah Health Clinics • Clients were older adults who would benefit from focused and intensive multidisciplinary care coordination and care management due to their highly complex medical and behavioral health needs • Faculty from Health Sciences and College of Social Work, and Community Case Managers

Camden Coalition Interprofessional Student Hotspotting Learning Collaborative Teams receive in-depth training to: – – support patient wellness identify and address social and structural determinants of health improve the coordination of health care and social services lead and participate in effective teams

Partners: Interprofessional & Multi-sectoral ACADEMIC PARTNERS • College of Nursing – Graduate Nursing • College of Social Work – MSW Aging • School of Medicine – Undergraduate Medical Studies – Ph. D Public Health • College of Pharmacy – Graduate Pharm. D • College of Health – Undergraduate COMMUNITY PARTNERS • Camden Coalition for Health • The Housing Authority of the County of Salt Lake • 4 th Street Clinic – Homeless Health Clinic • University of Utah Health Care – Enterprise Date Warehouse – Community-based Clinics

Team Formation • • • 8 teams of students from the different programs across campus Students were pre-assigned to a team Identified a client 1 client was assigned to each team 4 clients were residents of Housing First units 4 clients received health care within the University of Utah Healthcare system • Obtained written consent of the clients to participate in the program

Team Members Roles within the Team • Each team member had a role – – Team Scheduler & Data Entry Health Liaison Primary Communicator with client Primary Communicator with social worker • Maintain regular communication with client • Communicate with healthcare providers as appropriate • Communicate with case manager/social worker

Team Requirements • Meet in pairs in approved encounter locations • Not allowed to transport the client • Undergraduate students needed to be accompanied by a graduate student when visiting with a client • Communicate all encounters with team members • Communicate with case manager/social worker

Team Tasks • • • Establish rapport with client Communicate with client Determine goals of the client Model how to make appointment Model how to arrange transportation Coordinate with case manager/social work Meet the client at doctor appointments Suggest methods how to incorporate healthy lifestyles Arrange for support systems

Educational Outcomes & Student Value-Added • Teams learned to support patient wellness, identify and address social and structural determinants of health and improve the coordination of health care and social services. • IPE Hotspotting Teams were able to appropriately provide support and needs due to knowledge acquired through their own program and the Camden Coalition training: – – – systems-based practice social and health systems team dynamics communication advocacy

Outcomes Values: KSAs for All KNOWLEDGE Systems and community resources Health policy Health care financing Population health Public health systems Health care economics Social context of health Social determinants of health Roles & responsibilities SKILLS Patient and community advocacy Team-based care Coordination of care Systems change Systems interactions Community resources/needs Interprofessional communication ATTITUDES Cost-benefit consideration Social justice and equity Mutual respect and shared values Patient/populationcentered care Shared accountability

Data Values • Determining if there is value in Hotspotting based on data: – The current health of the client – Client’s usage of the health care system by assessing cost and claims data – Added value to education for members of Hotspotting – A value-based model of care – Utilizing healthcare Enterprise Data Warehouse to determine clients who may benefit from Hotspotting

Challenges • • • Recruiting student team members Obtaining access to data to identifying clients Obtaining consent from potential clients Maintaining initial team members Establishing a common secure communication system Accepting a client governors their goals and there are many barriers that may prevent achieving them

A Student Perspective on Hotspotting • Previous introduction to Hotspotting • Frontline, ”Doctor Hotspot” • Prior experience with multidisciplinary team approach • Identification of importance of teams in complex patient care • Acknowledgement of difficult system navigation • • • Complex illnesses and multiple providers Communication barrier between providers Health illiteracy • Interest in underserved population outreach and healthcare cost-effectiveness http: //www. pbs. org/video/frontline-doctor-hotspot/

About the Participant • Resident of Utah Housing First Unit • High-utilizer of the University of Utah Healthcare system • Multiple admissions, emergency dept. visits, & outpatient appointments • Multiple healthcare providers • Complex chronic physical and mental health disorders: diabetes type 2, hyperlipidemia, hypertension, migraines, obesity, PTSD, & depression • Health illiteracy • Difficulty managing medications • Social barriers

Summary of the Intervention • Performed weekly visits • Allowed participant to set goals • Practiced motivational interviewing • Included Housing First case manager in interprofessional team • Planned and discussed goals for health: food journaling, glucose logs, medication management, appointment attendance, and mental health journaling • Obtained voucher for mattress and bedframe for apartment • Encouraged consistency with mental health counseling • Assisted patient in creating diabetic-friendly grocery lists and navigating grocery store • Provided diabetic-friendly handouts and cookbook • Assisted in finding resources to support health promotion following Hotspotting graduation

Lessons Learned • • • Importance of interprofessional communication Focus: patient goals vs. healthcare team goals Care plan must be collaborative Strengths of team members vary Necessity of reflection Empathy vs. forced relating (Camden Coalition of Healthcare Providers, 2018)

Recommendations for Healthcare Personnel • Practice reflection and patient-initiated goal setting • Reflect on the importance of team • Attempt to communicate with interdisciplinary team members • Avoid labeling (e. g. , “frequent flyer, ” “non-compliant”) • Celebrate incremental change

What’s Next? • Continued interdisciplinary student involvement in Hotspotting • Consent more residents of First Housing units for future cohorts • Hotspotting alumni can assist in identify strengths/weaknesses to make improvements for future cohorts of Hotspotting • Consider tools within University of Utah Healthcare System to capture more high-utilizers and eventually expand Hotspotting

Questions?

References Camden Coalition of Healthcare Providers. (2018). Camden Coalition Hotspotting Curriculum. Retrieved from https: //www. camdenhealth. org/curriculum