Student Hotspotting Experience
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Transcript of Student Hotspotting Experience
1
Student Hotspotting Experience
Catalina Frau and Edsaida Ortiz from Ponce Health Sciences University, Ponce PR
Background
Primary Care Progress, the Camden Coalition of Health Care Providers and AAMC awarded twenty medical schools around the nations to participate in the Student Hot Spotting Initiative.
Participating Schools
➢ Cleveland Clinic/Case Western
➢ John Hopkins University➢ SUNY Buffalo➢ University Of Washington ➢ LSU/Tulane/Xavier➢ PSU ➢ Ponce Health Sciences
University ➢ Thomas Jefferson
➢ University of California-San Diego
➢ UMass➢ UNC – Chapel Hill➢ UNC- Charlotte ➢ University Of Chicago➢ University of Minnesota➢ University Of Rochester➢ Vanderbilt➢ VCU
To establish relationship among healthcare professionals to provide better services for patients, and promote Primary Care within the student community.
Mission
Catalina Frau Kimberly Feliberti Edsaida Ortiz Elisadel Figueroa, MD Janette Ortiz
Medicine Medicine Psychology Public Health Nursing
Malynie Blanco, MD
Faculty Advisor Social Worker Nurse
Andres Lebrón, MSW Luz Suarez, RN BSN
Mentors:
Super-utilizer Enrollment Criteria ➢ 2 or more admission in the past 6 months
➢ 2 or more chronic conditions
➢ Patient taking 5 or more medications
➢ Difficulty assessing healthcare services
➢ Lack of social support at home or in the community
Our Patient’s Story
➢ 30 y/o Hispanic male
➢ Past medical history: • Paraplegia • Uncontrolled DM type II• Recurrent complicated UTI’s • Pressure ulcers • Major depression
➢ Hospital admission: 2 hospitalizations the past 6 months
➢ Medications: 6 medications
➢Social History: • Lives with parents• High school education level• Limited income.
➢Health Insurance: Plan de Salud del Gobierno de PR
➢L e g a l S t a t u s : H o u s e confinement
Our Patient’s Story
Intervention Strategies➢ Weekly Phone Calls
➢ Frequent home visits
➢ Patient Education
➢ Homework assignments
➢ Interaction with family members and caretakers
Enrollment
• Bedside triage
• Qualification
Home Visit 1
• Initial Interview • Assessment of:
• Medical needs • Psychological
state • Living condition
Home Visit 2
• Diabetes education
• Motivational talk
• Medication reconciliation
Home Visit 3
• Delivered urinary catheter
• Review insulin regimen
• Prepare for PCP visit
Intervention Summary
Home Visit 4
• PCP Visit Summary
• Issues addressed: • Legal status • Compliance • Foley status
• Patient agreed to psychologic intervention
Interventions by Social Media
• Helped patient established rapport with PCP
• Explored insurance coverage for Nutritionist and Psych Evaluation
Home Visit 5
• Delivered glucometer strips
• Reviewed lab results
Home Visit 6
Intervention Summary
Utilization and Claims Data
0
8
15
23
30
Apr-15 Jul/22-August/14 Dec-15
Inpatient
C6 months Pre-Enrollment
Charges: $46,340.71 Inpatient days: 48 ER: 1
Post- Enrollment Charges: $0.00
Inpatient: 0 ER:0
Leng
th o
f Sta
y
Lessons Learned➢ Back-up plan➢ Scheduling and communication ➢ Importance of transition of care process➢ Patient rapport takes time➢ Social determinants affect access to proper healthcare➢ High utilizations costs can occur despite having care➢ Patient Education ➢ Teach back method to ensure understanding