1. Susan Hall, DNP, APRN, WHNP Cassie Kuhn, BSN, DNP Student April 2018
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

3. 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

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

5. 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.

6. 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

7. 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

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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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/population-centered care
Shared accountability

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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)

21. 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

22. 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

23. Questions?

24. References
Camden Coalition of Healthcare Providers. (2018). Camden Coalition Hotspotting Curriculum. Retrieved from