2016 Public Health Grand Rounds 02/19

PUBLIC HEALTH GRAND ROUNDS Linking Research to Community Health Improvement Jointly sponsored by the Department of Public Health Sciences & URMC Center for Community Health

(speaking off microphone)
- Good morning everybody, or good afternoon, I guess
it's 12:03 so I guess we'll get started.
Thank you all for coming to public health grand rounds today
this is a collaborative effort between the
Public Health Sciences Department
and the Center for Community Health
to bring you public health grand rounds
in the fall and the spring.
This is our second session and we meet at noon
on Fridays, the first and the third Fridays of every month.
So thank you for coming today and we look forward
to seeing you at the next session
in the beginning of March, yes.
Today is great I'm so excited to have
the Hotspotters team of 2015-16 joining us today.
Hotspotters is such a great initiative
started in Camden, New Jersey with Jeffrey Brenner,
and I'm sure the team will talk a lot about it
but really addressing the whole person in healthcare
especially among high-utilizers by using
an interdisciplinary team, so our team for Hotspotters
is student run, student led, student applied for,
student evaluated so really a great interdisciplinary
group of students that will be presenting to you today.
The students are sort of helped with an advisory team
and Dr. Telva Olivares from the Psychiatry Department
is the faculty advisor for the group,
and unfortunately she got called away today
so she can't be here but the student group
has it well in hand for sure.
Let me introduce the students to you,
Maria Carabela is a third year pharmacy student
and hospital pharmacy intern.
Josef Bartels is a fourth year medical student.
Jennifer Desiuez is a MPH graduate
and now into medical school, first year of medical school.
Kim Bui is a fourth year medical student,
so Kim and Josef are on their way out
and we're very sad to see them go.
They've done great work in our community
for health for sure.
Cassandra Barton is a nursing student,
and Natalie Wrafter, silent F, is a social worker
with experience in case management as well.
So the team's done great work over the last
six to eight months and we'll get a
taste of it today, so thank you very much.
- Okay so the name of our presentation
is putting the patient at the center of medical education
and interdisciplinary and longitudinal approach.
So I think a lot of you probably have this question
what exactly is hotspotting?
Some of you maybe have already heard about it,
it became widely publicized after a New Yorker
article written by one of my favorite authors, Atul Gawande,
written about Dr. Jeffrey Brenner a family medicine doctor
working out of Camden, New Jersey.
Sorry, okay.
It may go by a different name for some of you,
the model is similar to the medical home program
and nurse family partnerships.
And the idea does not at first really appear
to be all the revolutionary, but it has produced
some pretty impressive results.
Hotspotting is a method where we're focusing
healthcare resources where there's the
highest utilization of healthcare dollars.
And Dr. Brenner probably explains it most eloquently,
so I'll let him do the talking here.
There we go.
- [Dr. Brenner] Executive Director of the Camden
Coalition of Healthcare Providers in Camden, New Jersey.
Camden, New Jersey is a city of nine square miles
and 79,000 people and our goal at the Camden Coalition
is to figure out how to deliver better care,
at lower cost, to Camden city residents.
Healthcare hotspotting is an idea that was borrowed
from William Bratton's work reforming
the New York City Police Department.
A small number of citizens are committing many of the crimes
a small number of patients are returning
back to the healthcare system over and over,
and in many large systems it turns out that
a small number of individuals are driving
much of the costs and much of the utilization.
Being it healthcare, education, policing,
all of these systems struggle to pivot
to the day-to-day needs of outliers.
In healthcare hotspotting, and hotspotting,
is the strategic use of data to
target resources to outliers.
There are a certain subset of patients
in the American Health Care System, 1% of patients,
who go an extraordinary numbers of times to the hospital.
In Camden, New Jersey there's a patient who went
113 times in one year and 324 times over five years.
In the city of Trenton there's a patient who went 450 times,
these are patients who are outliers.
If you made a list of everyone in the city of Camden
who went to the hospital there's gonna be
a small number of patients who are gonna be
in what's called the long tail of data.
This is the end of the bell curve,
and this is a messy non-linear part
of the data set these are patients with
extraordinary utilization and we call them super utilizers.
- So Dr. Brenner was referring to police commissioner
William Bratton who championed an approach
that used data to map crime.
And used that data to direct police shifts
and resources to those areas of hotspots.
In order to sort of translate that to the medical system,
he got data from three hospital systems
in the Camden area and was able to focus
health dollars and health resources to those areas.
You know the usual medicine isn't always sufficient.
Ailing patients sometimes need a social worker
more than they need a physician
to control their blood pressure.
Sometimes they need advocates and more social support.
Sometimes they just need help navigating
a torturous and obscure health realm.
And really they shouldn't have to choose.
Part of patient-centered care and hotspotting means
that we address all those needs as they arise.
And we can do so because we work
in professionally diverse teams,
and each member has different strengths
to address variable needs.
So the next half hour we'll tell you what we've
been doing as the health team in Rochester, New York.
- So one of the things that Dr. Brenner didn't talk about
was his years of struggle before he
figured out how to do it basically.
He graduated residency in Seattle,
then moved and took a primary care job in Camden
and was basically hitting his head
against a brick wall wondering why his patients,
a fair number of patients were so unhealthy
and why he was powerless to change it.
And so what we're involved here with student hotspotting
is actually Dr. Brenner's idea is implementation,
is trying to say, "Okay I found something that might work
"let's test it on a wider scale,
"a public health intervention,
"and can we get it out on a wider scale?
"And how can we take advantage of medical students
"and their idealism and community outreach
"that they already do in order to get this out there?"
So Dr. Brenner being wise decided to pair
and use his networks in a number of organizations,
well-known throughout the U.S. including
the American Academy of Medical College the AAMC,
and Primary Care Progress and came together and said,
"Hey, what if the AAMC gets on board with helping me
"get this out of Camden, New Jersey
"and try it out in some different cities?"
And so in 2014 they actually launched a nationwide
grant competition for medical students,
that had to be multi-disciplinary,
to apply to learn how to do this and to actually
implement it in their own communities.
We had a team here in Rochester in the very first cohort
and then the team standing up here today,
is the second cohort and we kind of learned some
from what they, the mistakes they made the first time,
and took it the next step forward.
So, you know sort of the ideas here on the picture
is that you can learn a lot from one patient
and I think as we go through this presentation
you'll just see how, what a deep impact it had
on all of our learning here and our
potential plans for the future.
So we'll just introduce ourselves,
I guess we were introduced at the beginning,
but we'll introduce what school we came from
so you can see the sort of interdisciplinary nature.
So again, I'm Josef and I also completed my
public health degree last year
and I'm a fourth year medical student.
- I'm Kim, I'm also a fourth year medical student
going into family medicine.
- I'm Maria, I' a third year student at the
Wegman's School of Pharmacy at St. John Fisher College.
- Hi everyone, I'm Jennifer I'm a first year
medical student at the University of Rochester
and earned my MPH last year.
- I'm Natalie, I'm a master's of social work student
at the Greater Rochester Collaborative Social Work Program
with Brockport and Nazareth College.
- And I'll introduce, Cassandra Barton,
is actually in Portland, Oregon she finished
the accelerated nursing degree here and is now
working as a nurse at OHSU in Portland in trauma surgery,
I believe or maybe just emergency trauma I'm not sure.
And then also Dr. Green didn't mention herself as one
of our main mentors through this process,
so Dr. Green and Dr. Olivares,
so always leaves out herself.
So how did we do this?
We were given pretty broad, a pretty broad
reign in terms of how exactly
to design our intervention here.
From talking to the team last year,
we loosened up the inclusion criteria,
and the exclusion so we could capture more.
And then, so the question is how legally
and privacy and all that stuff,
how do you go about identifying who's using
the healthcare system the most?
So what we did was we recruited a few other
preceptors into our team both from nursing
and from social work across the hospital and then
and listed when a patient was under their direct care
they would ask their patient,
"Is it okay if we introduce you
"to a team of medical students?"
And then we would go in and basically
do a standard enrollment in terms of getting
permission to access their records
and to follow them and if we could follow up with them.
The initial conversation was very interesting
and I think it actually underlines an advantage
of medical students is that we could really
align with them as peers rather than as
top down figures so we could say,
"Would you be willing to help us learn more
"about the healthcare system and how it works
"or it doesn't work for you?"
We found that to empower the patient,
to really help in our education people
were more than willing to say, "Sure that sounds great.
"How can I help?
"I'd love to help doctors be better,
"or nurses, or social workers, or pharmacists."
So the specific criteria you can see up there,
these were things that just sort of helped us
iron in on the patients who weren't having
just an acute, okay well it's just these three
months we're in the hospital a lot.
Having these things over a longer period,
sort of identified patients who were
likely to continue using a lot,
and then the exclusion criteria discussed.
So who exactly were they?
(Mumbles) middle age, we excluded patients who were
nearing end of life, we had a diverse group of races,
and then where in the city, is not the exact addresses,
don't worry but just so you can see the five different
spots in the city all northern Rochester.
Not a surprise but if you overlie this census track data,
on top of that you can see it's not in the very
poorest section of the wedge but it's not far away
where these patients are coming from.
And so you start to think about the social determinants
and what exactly defines who is gonna be sickest
and who is gonna use our healthcare system the most.
- So I'm going to introduce the patient we're
gonna talk about today, this is Jay L.
He's a 62 year old Caucasian male.
He has a lot of cardiac issues,
high blood pressure, I believe he had eight
admissions to the emergency room in 2015.
He suffered a traumatic brain injury
right after graduating high school so many decades ago,
and ever since then he's had a lot of trouble
with cognitive functioning, a real lack of social supports,
so he really struggled maintaining his health.
We split our team into two teams,
so he worked with me the social work student,
Kim the medical student, and Maria the pharmacy student.
And now Maria's going to talk
about some of the interventions.
- So in terms of our patient we had
bi-weekly visits with him face-to-face.
We wanted to stay in constant communication with him,
to ensure that he was getting
the assistance that he needed.
That also included phone encounters,
pretty much every other day.
We also went with him to his PCP and cardiologist visits
and there we wanted to make sure that his
concerns were being taken care of
and that his medication regiment was actually accurate
so we worked to do that with
both the PCP and the cardiologist.
We also worked with an organization
called the Learning Resource Outreach Center
and in that photo here this is Andy Carey.
He pretty much leads the Learning Resource Outreach Center
and he helped us with so many issues that were going on
in terms of legal issues, housing issues,
so he was a really, really great help.
So I really wanted to talk about him a little bit.
So some of the things that we discussed was
backwards planning, so we discussed the patient's priorities
and worked to solidify those issues and then we also
looked at medication adherence, we also wanted to teach him
how to self-advocate, and make sure that
he showed up to his actual appointments.
So the patient's priorities were his legal issues
that needed to be resolved and with the help
of LROC they were resolved quite quickly,
I mean within about a month of us working with him.
He also was living in a very dangerous environment.
His home had been robbed previous to us working with him.
Copper was taken out of the house so we helped him
to sell that house and then get him into
a better living environment, and that actually
took the longest for us.
It happened after we actually stopped working with him.
It just happened a few weeks ago.
Took a lot of work though but we finally got him
some a nice home to live in.
We also helped him to eat more hot nutritious meals
when we had first started working with him.
He was only eating potato chips and soda,
so Natalie was gracious enough to give him
a list of soup kitchens in the area
and go over nutritional values.
In terms of the clinician's priorities
we worked to increase his attendance
to his doctor appointments, his medication adherence,
so at first we noticed that he had a brown bag
of all of his medications so what I did was
I set him up with a pill box to see if that would work
and it increased his medication adherence.
I actually worked with another pharmacy
to get everything, all of his medications into
multi-dose packaging and actually delivered to his home.
Another thing that we worked with him on
is to get him in touch with his social worker
who would contact him regularly and also
Natalie found a home care management team
that specializes in traumatic brain injuries
and so they work with him regularly now
to make sure that he's up to date
with his medications, and visiting the doctors.
- So as much as we accomplished it's not always
captured in the cold, hard numbers of utilization.
Not to say that our intervention with five patients
could approach statistical significance
no matter how different the bar graphs are.
But you'll notice here there's if anything
a trend of what might go the wrong way.
So I think it's important to realize sort of the limitations
in that how much we did, there were times where we all
had class or we all had a test or something
and one of our patients needed
something and we couldn't get there.
So it's not a perfect, this is not a solution,
for long term social medicine within our community.
At least not if there's only five, six of us.
And we haven't finished learning exactly
how to do it, so in many of these cases,
you can see that before we started seeing the patients
most of the patients we met either in July or August,
so there's the graphic is split-up basically
the first half of the year and second half of the year
and basically we spent four months with the patients
in the second half of the year during the red bar times.
And you can see that some of the patients
even went to the ED more, but again,
you can see all the progress this is an example
that Maria just gave is just one of our patients
and Kim will talk a little bit in general
about the overall successes we made in ways
that can't easily be measured in bar graphs.
So I think it, it will kind of be
a little bit of a theme.
Outpatient visits however in a couple cases
we were able to increase a lot, some of the patients
we would recruit and they would have just
lists of no-shows that would go on
for the whole eRecord, you know it was just
every single appointment they would miss.
So even getting the patients to some
of these appointments was really valuable.
- So far inpatient days for our patients
for actually most of the patients that we've actually
worked with we saw a trended decrease in
the number of hospitalization days.
One patient was hospitalized so much for conditions
that were very systemic and sort of,
ever since she was a child,
so we actually didn't get to work with her as much
as we would like to and she was actually
hospitalized for most of our intervention.
We didn't have cost data for after intervention,
but for the first half of the year you could just see
I mean enormous costs to the hospital system,
most of our patients are approaching $40,000
and that is just within the Strong Medical System.
We actually weren't able to get the cost data from RGH
and actually that's true for all the other data, as well.
Even for inpatient days we know for a fact
that this patient was hospitalized at RGH
as well as these two patients and that
they were not at all accounted for in this data.
So that was actually a big barrier in terms
of getting accurate data was just the difficulty
with operating between multiple medical systems
and multiple hospitals within the Rochester area.
- I thought there was a pretty poignant sort of
quote that struck me and it actually came out yesterday
or two days ago in the New England Journal of Medicine
it was an opinion piece and they said,
"What if financing of cancer care
"was held to the same standards that hotspotting is?
"Suppose doctors in hospitals are paid for cancer care
"by capitation, or bundles, or penalties for readmissions.
"And were paid directly and adequately
"to keep people out of the hospital.
"Oncologists might begin lamenting that
"although new approaches to cancer care
"help patients they just couldn't get the return
"on investment to work.
"And the outlook for population health
"might become less financially gloomy."
So I think it's important to keep in perspective
sort of how, what a stringent requirement that is
to say, "Well is this cost effective?
"Are we actually saving money by achieving
"all the positive things that we achieved
"with our patients in terms of getting to patient's house,
"getting patients to out patient appointments,
"improving their food situations and medication adherence."
It certainly didn't pop out in the numbers
at least initially there might be some delayed effect
but also sort of the whole it's important to take
a step back and think about the whole paradigm,
and is cost and sort of investment and
thinking of it in terms of utilization,
while that's the way to sell it to funders often,
is it actually can we make sure
to keep it a dual perspective, as we move forward
with community health interventions in general?
So since Cassie's not here, we wanted to just,
we wanted to move on to part two of the presentation
is really sort of the impact on us.
We showed you a little about the impact
on one particular patient and the
numerical data that we have overall
for impact on all five patients from
within one health system but then,
we want to focus the second part of the presentation
on the impact on us and sort of the dual
possibilities for positive change both within
the community and within the learners
who participate in experiences like this.
So the first question that we asked Cassie,
and she's in Portland, was how has it changed
the way you interact with patients?
So just to have a nursing perspective here.
- [Cassie] Hotspotting has changed the way
that I interact with patients
by really allowing me to put patient's needs first.
I think that before hotspotting I would look at
a patient case and I would say,
"Oh great I can identify the top few things,
"that I know that if I help them do they'll be
"happier and healthier, and maybe that is being able
"to find a way that they can take their medications easily,
"finding transportation for them
"to and from doctor's appointments,
"and making sure that they go to all
"of their dialysis appointments."
But what I realized was that my patients
may actually have 10 other things
on their list of priorities that come before mine.
And that, if they don't value what I value,
they're not gonna be invested in
working towards those goals.
So what I've learned is to really approach
my patients and say, "What's your priority?
"What's most important to you?"
And what may be their number one is not finding
medications or taking their medications every day,
but that's finding a different place to live.
Maybe they don't feel safe in their housing situation
and if I can help them with that then I feel
this greater level of trust showing them
that what's important to them is important to me.
And that I really am there to help them achieve their goals
and maybe down the line we can work on
some of the things that I've seen
to be important changes.
- And so we talked, the group, we all sort of
did our own brainstorming on some other questions.
Well what was the impact?
What impact do we think we had on patients?
And overall we thought we had
a positive impact on their lives,
often increasing the amount of
social contact they had significantly.
Our views on the healthcare system all changed
dramatically even people who had already
completed a public health degree or already
were pretty well-educated within the discipline.
We just got a completely different perspective
that we would have never gotten
in a clinic, or in a hospital,
or in an ED just to be outside of the actual system itself
and in people's houses and traveling with them
between appointments and I mean, I had no idea
how medicabs worked, you know what I mean?
It's just these little things that you get.
And then the potential for curriculum.
I think we all have different ideas
because we're in different schools about how to
fit it in and how it might work.
But I'll talk about that a little bit later.
(speaking off microphone)
- There we go.
So Maria's here but she's still gonna show
us some videos (laughs).
We'll talk about her perceptions of patients.
Yeah, so first question was how has your perception
of patients changed after working with hotspotting?
These are brief.
- [Maria] So one of the main things that I learned
while working on the hotspotters project is that
health is not everyone's main concern.
What I did find that was helpful was finding
motivation for the patient whether it be
their job or loved one.
- And we asked Maria if she thought that
if we had a positive impact on our patients.
- [Maria] As a pharmacy student I think that
implementing the hotspotting project into
pharmacy school curriculum would be a wonderful idea.
I believe it would give students more of
an opportunity for a hands-on approach to learn more
about healthcare programs, especially in the Rochester area.
And I believe that it would teach students that
there really is no standardized approach
to working with patients,
and that healthcare should be individualized.
- Great so that was actually
about the curriculum involvement.
Hopefully this is about it being effective (laughs).
- [Maria] I believe that the patients that we worked with
on the hotspotters project were greatly impacted.
There were times where we would receive calls
from patients thanking us for all of their hard work,
and being available to them whether it be
in person or over the phone.
I also believe that the patients made a huge impact on us.
There are so many facets of the healthcare field
that I learned from this project and I don't think
that I would have ever learned them,
or I would have learned them years from now
if I hadn't been given this opportunity.
And the last question centered around
how our perception of the healthcare system
has changed after working with hotspotting.
- [Maria] Since working on the hotspotter project
my perception of the healthcare field
has changed immensely, prior to the project
I had no idea that there was a healthcare management team
that specifically helped patients with previous
traumatic brain injuries and I thought that
that was very helpful to the patient
once we signed him up for that.
- So I tried sort of formalize all of the things
that we learned as students came up with several themes.
So about the system, I think one thing
that we all struggled with was how the system
is really not patient-centered
and not really well interconnected.
You know 10 minutes at a doctor visit
where one complaint is heard and the rest is dismissed
I think is frustrating for patients and I think
also sometimes for us as providers
for feeling that we don't have enough time
to really address all of the complaints
that our patients are presenting to us.
Trying to even parse through the data
with Epic and Care Everywhere,
where even though we have some access
to other healthcare systems it's
definitely not perfect and we found
a lot of frustration with that as well.
We found that one size doesn't necessarily really fit all.
The work that hotspotting does and other models
that are similar to it is difficult,
there's no perfect way of doing it.
There's no way of learning how to do it
without actually just doing it and hitting
the road bumps along the way.
And some patients they need different things.
They need an advocate, sometimes they need more.
Sometimes when you get more involved
than I think you are initially comfortable with.
And sometimes you can't fix the problem, and that's okay.
It doesn't necessarily mean that it's a failure,
sometimes it's just a matter of time.
One of our patients, actually the one that we presented
at the beginning of our presentation, had to vacate his home
because of those extenuating circumstances.
He was actually living out of his car for a little while,
and this is all during the time
that we were working with him.
So, and we were just notified last week though,
because we had connected him with the social worker
he was able to actually find permanent housing,
and that's something that I think we just had to wait
and I think not become discouraged because
feeling that we were being a failure,
it was about really just a matter of time,
and we I think found him the resources
that he needed at a timely manner actually.
We also found some desensitization among many providers,
because I think they've been conditioned to believe
that there is just one way of doing things,
and what our efforts are doing may not actually work.
Because of limited time, and they don't really know
a better way of doing things.
It's difficult I think to address,
to really introduce new changes
into an established care team already.
What we learned about helping others,
I think continuity is key.
Social support sometimes requires crossing
those professional boundaries.
When we visited the homes of the patients
that we were working with it was sometimes
sort of difficult to stomach.
The House of Mercy was definitely a place
that I think a lot of us had not been exposed
to in the past and seeing sort of
the two square foot area that most patients were,
that our patients, were living in and the disorganization
of their lives was very difficult to stomach.
And then also gave us a huge perception into
what they were managing on a daily basis,
and gave us context for how they
were approaching the medical system.
And I think one of the huge things that we've
also come away with his how stigmatizing
labels can be and how they can really impede humane care.
I think it's easy for providers to say
someone's a drug seeker, someone is non-compliant,
but understanding how all of their medications
may be in a brown bag, and how all of their belongings
may fit on one couch can really make you understand
that it's not about compliance it's about
what they're able to do with the resources
that they actually have.
- So much like Kim sort of summarized
the lessons learned by students,
I sort of went and took the question
about curriculum potential and put it into one.
But I wanted to go back because I thought
Cassie said it well from a nursing perspective,
in terms of the curriculum potential.
- [Cassie] A standardized hotspotting curriculum
in nursing school I think would be really beneficial
to help broaden nursing students
understanding of patient lives.
I think specifically of the home visits that I did
and how seeing how patients lived and the condition
of their homes really hit home for me
on patient specific nursing interventions,
or how you provide education to really help
to see the broad pretty diverse way that patients may live.
And how you can't only take one situation
with a standard intervention that you have to
see the whole patient and be able to make changes
based on their individuality.
- So I thought it was really powerful to hear
from a nursing perspective which nurses
didn't really need the word patient-centered
because that's what nursing is patient-centered.
But even from her perspective to see how much more
her view was broadened through these
the longitudinal experience.
So we thought, hey there's real potential here.
We spent a lot of time, we'd love to get
other people involved, but other people said,
"Well that's a lot of time.
"What do I get, or how is it protected in some way?"
One of our objectives as students here presenting
to a broad audience is to sort of continue
with this momentum and explore possibilities for
getting it as a stable part of the curriculum.
And we thought that hotspotting in general
would be able to address two needs that I know
the medical school struggles with and I think
the other professional schools as well.
The first one is how do we start working in teams
and how do we get that going early?
And so this was an amazing opportunity.
I had no idea what the training of a social worker was like,
or all of the things that they learned in pharmacy school
besides the mechanisms of how drugs work.
And so it was really valuable to know these people
as friends and then in the future it will be
much more comfortable with even if it's
not the same pharmacist to go up and say,
"Well I really need help with this, and this."
To really see people on the same level
rather than the hierarchy that so often,
that we're so often met with.
So we looked into the literature a little bit
and we have that other places have piloted programs
but haven't used hotspotting before.
So we would propose this as a way to start
this interdisciplinary approach very early.
Then the other thing that Dr. Green
and her whole department is trying to do is
and has done with great success already,
is to really integrate our university within the community.
As you saw from the map, and sort of where our patients
came from we're way down south.
We're not really in the greatest need areas
of our city, although we're not far.
But how can we have greater interface and exchange?
There's already a system of free student clinics,
they're located in different places through the city
and people volunteer ad hoc basis,
but there's, I think there's opportunity
to do more and this certainly created
an opportunity to really get out in communities
and to meet people and for people to be like,
"Oh the medical students are coming by again.
"Ms. So-and-so is over here today."
Just sort of impressed that we were back again
and that sort of that we cared about those things.
So I think those would be the two
from the medical school side and I think the other
professional schools as well would be able
to address those two things.
And then the idea of this whole longitudinal.
What is the value of following a patient over time?
We know from a clinician's perspective that a longitudinal
relationship improves health outcomes.
There's not really a question about that.
But in terms of a learner perspective, what can we say?
We know from the patient's perspective
and our experience here, that the longitudinal aspect
really, really helped.
But in terms of the learning can we say that it did?
And I think we all came around in our sort of our
focus group questions that, yes it did.
We wouldn't have been able to get to those same places.
We wouldn't have been able to get
into some of these home visits.
You can't just ask somebody to go into their house,
it all builds on this relationship and this trust.
And it also fostered our ability to establish
longitudinal relationships in the future
and to work to, to work within our clinical setting
in the future to ensure that
there is a longitudinal relationship.
So we think that this is a great opportunity
for the medical school and the other professional schools
to have this instilled early and to realize
the value of this early rather than
having to come and dig through a patient's chart
and get the whole history and try to understand
the patient in an hour consult,
when they pop onto your floor and you're
the social worker and you've never met this patient before.
So, we decided
to see if we could pilot it actually,
so there is a group of medical students
Your Street Outreach, here, that have been working
with homeless population of Rochester since 2010.
We said, "Hey can we share some of what we learned
"with the hotspotting model, in terms of establishing
"a longitudinal relationship
"and focusing on backwards planning?
"Can we try that in your model of bringing
"medicine to where people are on the streets?"
And they said, "Yeah, great.
"But how are we gonna do this?"
We said, "Well we always introduce
"ourselves in the hospital."
And they said, "Well we've never been allowed
"to see the medical records so we don't know
"when our patients come to the hospital."
So we've been working with social work
and Dr. Green, and a few other faculty,
to establish sort of what we're calling
inpatient response team so it's
homeless inreach and outreach.
So we can establish a point of contact
when a homeless individual comes into the hospital,
and then we can follow them longitudinally over time
wherever they go, rather than hoping they show up
at the campsite that we already know
about out in the community.
I think that's what I wanted to say about that,
and finally so the title of that.
Is it time to sort of re-evaluate
the University of Rochester's emphasis on social medicine?
Rochester for a long time has talked about
biopsychosocial, but aside from Montefiore
and UCSF the idea of social medicine
has sort of left the vernaculum.
So is it time to sort of bring that back?
And to think about, okay we have these
social determinants of health, and it's getting pushed
more and more but what do we do about it?
And is it time to use hotspotting as a
potential tool to fill that need?
So, we wanted to acknowledge our patients.
A couple of them actually were trying to come today
but transportation is difficult,
both to medical appointments,
and to grand rounds presentations (laughs).
But they were really wonderful
and we learned from them.
Our mentors, Drs. Olivares and Green,
one of our main recruiters Zatel.
I don't know what floor she works on now
and Andy Carey the social worker.
We also really wanted to thank Dr. Lambert
for helping this happen, it's a matching grant
so the school had to match the money that the AAMC gave,
Camden Coalition and Primary Care Progress, oops.
We have some references, but if you want references
contact any of us and we'll send you the whole list.
And this was we had as part of the training for this
we had a conference in Camden, New Jersey.
We all went down there and did some
workshops and orientations.
We would be happy to use our last 10 minutes for--
- [Woman] You should thank, Brenner.
- And Dr. Brenner's on the far left, right (laughs).
It's different.
(audience applause)
We can all answer questions.
- Does anyone have any questions for us?
- [Woman] I have a question about when you were
evaluating patient's priorities and goals,
were there some key questions you asked them
to hone in on really what was realistic
and possible for you to address?
- [Josef] You might want to talk about
what backwards planning is.
- Yeah, so we were actually given a template
for backwards planning from the Camden Coalition
when we went down to the workshop during the summer.
And it had some already templated questions
for us to ask them, we kind of went through
the different options and it ranged from
like Josef mentioned medications, or housing.
It really had a really broad spectrum of questions,
that we could kind of go through step-by-step
with the patients and then we kind of organized
it from highest priority on the top using these
little paper slips and then went down
to the lowest priority on the bottom.
And then we kind of asked follow-up questions
to the patients, how important is this?
Is this something that you want to put
on the back burner for us to try to get to later?
Or is this something that's really a priority
right now that we should focus on at this moment?
- [Woman] Were there home care nurses involved
in any of these patient's lives?
- So at least for, yes there were home care nurses involved.
One of the things we ran into was that
for one of our patients the home care nursing agencies
had fired the patient basically because
she was so difficult and so reticent to be involved
with the system in general.
So in some cases all of the supports that
we have in the community already had failed.
Any other home care nurses,
you guys worked closely--
- Yeah so the patient that we discussed earlier,
we had decided to implement a home care nursing
program for him because it took us a while
to really get to know him and once we did,
we learned that he had that traumatic brain injury
so he had some serious cognitive difficulties.
And we knew right away that after we stopped
working with him the adherence,
the visitations to the doctor's office,
was just going to plummet again.
So that's when we decided to sign him up
for that and when we received the call
that they actually spoke with him,
and that they're gonna start working with him,
we were so excited.
Because that was our main worry.
We just didn't want all the work that he did
to just for him to go 10 steps back again.
So we signed him up for that.
- And in another case it was interesting,
we met a barrier the patient actually
fired the home care nurse because there was
an unwillingness to cross boundaries
in terms of, "Well I'm a nurse I don't do this."
And the patient really needed support in terms
of like cleaning her dishes 'cause she was
wheelchair bound and has one leg.
And they weren't able to do that because
it wasn't in their job description so that was
one of the points we had about you have to
kind of bend the silos that we're in and say,
"If this is gonna get my patient healthier
"to be able to eat food because the dishes are clean."
She didn't have a dishwasher and couldn't reach
the sink you know, but nobody would pay for somebody
to go wash her dishes.
It's like we'll pay for a visiting nurse,
but the visiting nurse says, "I don't wash dishes."
So it was that sort of thing we ran into a lot of.
A pharmacy that delivers drugs, but they don't deliver food.
Those sort of, those barriers.
- [Woman] I have a question but I wanted to first point out,
I may have missed this in the beginning.
But in addition to volunteering all of their time
working with the patients these guys all sat
through webinars every what, once a month,
every couple of weeks from Camden teaching them
different aspects of hotspotting.
They attended two seminars in New Jersey,
where they learned, for two full days really basically
concepts around social determinants of health
and how hotspotting can work.
They worked with other teams throughout the country
so these are hotspotting teams from different universities
across the country that worked on this process as well.
So without getting paid and without credit,
they really put a lot of time and energy
into learning this, trying to integrate it
into the curriculum across several schools,
and also enhancing their own learning,
and above all helping the patient
so kudos to you all for sure.
So my question is a change that happened this year
and hopefully an improvement, last year
the team had a real hard problem passing off
the patients, so when the grant ended
and they could no longer be involved with the patient
there was kind of a lack of continuity,
what do we do with the patient now to build this
support structure when we're gone?
And this group was kind of charged with fixing that
so that's kind of a hard thing to fix.
But I wonder if you all can speak to that
certainly the home team helps a lot,
but integrating into primary care teams a little bit?
- Yeah and so with the patient that we talked about
it was mainly the home care management team
we just didn't want him to go back to the environment
that he was living in before
and since I wasn't going to be there with him forever
to help him fill pill boxes that's when
we got the pharmacy it's called Saratoga Pharmacy.
They're actually really, really great.
They fill multi-dose packaging prescriptions
and then they deliver them right to the house.
So we wanted to make sure that where
we ended with him would just continue on.
We knew that there would be bumps along the road,
but the nice thing about that
going back to New Jersey after the project technically ended
we heard that other teams kind of were continuing
on as well and we were like,
"Oh let's call our patient then and see how we're doing,"
or how they're doing so we have actually
done a little bit of that still.
I know Kim's talked to the patient, right?
- [Kim] Yeah.
- And in terms of thinking of the future
it would be something, well can we think of it
in a longer scale.
We know that a three month intervention
it doesn't really qualify as a longitudinal,
as anything longitudinal--
- Especially when they have housing issues.
Takes a long time.
- [Woman] Which is a lead into my question
which is have you given thought to how this
could be broadened and institutionalized?
You were able to be involved with about
five patients is that correct?
What about making this bigger, getting to more patients?
Have you thought about how you would do that?
- I have for the pharmacy school,
and I haven't figured it out yet, so (laughs).
It's a lot of work.
- As far as the medical school the next step for us
is to write a proposal to the senior associate dean
sort of summarizing the potential.
The things that we've done to broaden it initially
have been to take it to the Your Street Outreach group,
and get it so they can use these techniques
for longer than three months with their patients
who end up coming through the hospital.
And then there is real potential and we've been working
with the director of humanities,
Dr. Stephanie Brown Clark, about how can we explore
humanities credit and making it either
an elective that you can do during third and fourth year
in your clinical time or one of the humanities classes
that happens in the first two years.
But I think, and Dr. Green, as the director
of the community health improvement course,
is also exploring avenues to bring it as part of
the distinction track in community health
throughout all four to be involved in this
from the beginning of med school through
obviously taking a pause during the
third year of medical school somehow.
So that is sort of one of the major thrusts
of our presentation is yes, but also help.
And how can you see to broaden this into
because of the value both to the learners
and to the patients, what ideas do you have to broaden?
- [Woman] A question about methods.
So you followed five patients,
how many did you was there a standardized (mumbles) process
or form as you know English as a second language
did that have any bearing?
Also have you thought about including nutritionists
in your group because diet and diabetes medication
all of those (mumbles) play
a role in overall health outcomes?
- Sure, so I'll address your first question.
So we actually probably approached three times
the number of patients we actually recruited.
The way we recruited them was actually going
and talking to Dr. Olivares and other providers
in the community who said,
"Who are your most difficult patients?"
I think the way that Dr. Brenner has done it
in the past is actually looking at the hard data
and seeing who was taking most of the healthcare dollars.
Trying to approach that, what percent that uses
over a third of medical costs.
So we did not have access to all of that data,
and actually I think using physicians who were
already well-acquainted with the most difficult patients
I think actually is a pretty good method
of recruiting especially for our group.
We would love to have different professionals in--
- I can speak to it.
- Yeah go.
- I actually did reach out to the dietitian program
at Cornell because I know they rotate up here
and I had met some of them on the floors.
And the timing actually just didn't work out.
It was when one class was ending they just weren't
in Rochester from July through September.
So that would be if it was implemented
it wouldn't just be these three months.
I think the dietitians should,
and will be, involved definitely.
For the next cohort I think Jen will talk about
moving forward in this, the pure hotspotting model
before we've really adopted it to Rochester.
I know she's looking at some other schools including
perhaps clinical psychology program, dietitians.
- [Woman] Business school.
- Business school or even school of education.
A lot of these things we think cut across disciplines
so much that you don't need the medical skills as much.
- [Man] In your program and looking at the number
of folks that also participated from other areas,
as you got together how similar or different were your
experiences and especially for the previous graduates
of the program how have they been able to
implement this experience in their
own education and career?
- So our own expectations coming in were very different.
I think we had no idea and it took a lot of time
to sort of, we did a lot of social events
among ourselves at first to get to know
sort of what is nursing school?
What do you do in nursing school?
That kind of thing.
As far as the second part of the question,
can you repeat the second part?
- [Man] The second part of the question
was all of the other groups did they
have a very similar experience to yours?
Or was it quite a bit different
in helping and assisting the patients?
- So talking to some of the other students
at both the events I noticed that
all the teams were at different places.
There were some teams that jumped right into it,
like technically this was the kick-off
so we hadn't really started yet.
But some teams had like three patients,
and then there were some teams at the end of the event
that were like, we didn't even have any patient contact
because we were too nervous about home visits.
So, I think our team we really jumped into it.
We were really comfortable with meeting with patients
but it kind of just depends where the school is
at with that and how comfortable they are.
- Our preceptors really helped sort of
either cutting through red tape,
or telling us not to worry about the red tape.
(audience laughs)
So that was a big help and some other schools
the lawyer said, "No you can't do anything,
"you can't look at records, you're medically,"
so they would not allow anything to really move forward.
I think there was part of your question too about
the students who did this last year in the previous cohort
are they implementing it?
And for the medical side they're interns right now,
so they're not doing anything.
(audience laughs)
Except for taking care of their patients.
Yeah they're doing a lot.
I don't know if you've had contact with your
sort of twins in the previous year?
- I had a little bit of contact but it was mostly
he was asking me how his patient was doing
to check up on her and she was actually doing really well.
- We'll take one more.
- [Man] I think it's clear you got
a really amazing experience, you did a great job
by getting out of the hospital, out of the doctor's office,
and going to where the patients are and stuff like that.
You brought up a couple of things that you
learned along the way in your lessons
of people need somebody to wash the dishes for them
if they can't wash the dishes.
Are there other sort of bigger picture insights
you got from what you did about what leads to change
to shook the whole curve--
- [Josef] Healthcare system?
Should we play Cassie's healthcare system?
- [Man] Well if not in the healthcare systems,
social determinants as well, and the community as well.
- Well one thing that I learned is that
there are actually a lot of programs
in the Rochester area that can help
with the social determinants and healthcare,
and I think the biggest issue for me
is that if I don't know about them.
If I didn't know about them before,
who else doesn't know about them?
And that, that was really concerning for me.
So I've been trying to work with my school
to see how we can get the word out there
on these different programs, so that if there is
another pharmacy student even on rotation at the hospital
they can say, "Oh, yeah I heard about this program.
"Let me call them and see what we can do for them."
There's a lot out there I just
didn't know that they existed.
I don't know if you guys.
- For me the biggest thing was when you hear the stories
we learned a lot about trauma informed care.
So we explored a lot of sort of childhood histories
and how patients got where they are,
and why they are who they are.
And for me the biggest takeaway was how early disease
starts before you can measure the blood pressure,
before the diabetes hits, it all goes back to
well what was the home situation like?
What was the early life experience like?
And so that for me was the biggest takeaway
is that you can't really come at somebody
who's 48 and now is at advanced kidney disease,
and one leg, and a couple addictions
and expect to make too much progress.
I don't know the solution, Rochester has a great
anti-poverty initiative started and there's a lot
of people very active.
My favorite was the one social worker
that we met with who was like,
"What about the anti-affluence movement?"
And so he goes out in Pittsburgh and says,
"These things are connected affluence and poverty
"are connected you can't just address one
"without addressing the other, so."
He may be a Marxist but (laughs).
But it's certainly something to think of, you know.
We have a lot, we certainly have the resources
within our community to end poverty.
Utah has ended homelessness of all the states,
so I mean let's go New York, come on.
- Yeah and I think part of the difficulty
in trying to answer that question is that
what we've learned is that this is sort of
really big, messy work, and it's something
that I think is so patient specific.
In trying to sort of address all of
their social determinants of health without
actually reforming the health system,
the resources that we're putting into
social programs we are sort of stuck
with a broken system that we're trying to work within.
And I think that in that respect the way to do it best
I think is to form the relationships that we did form
and I think that was sort of just a matter of time
and a matter of sensitivity and trying to be
open-minded about what is really impacting
the people that we're working with
and that we're interacting with on a daily basis.
- So unfortunately we are going to have to cut it here
for time but I'm sure the team will sort of linger
if folks have additional questions.
Please make sure to fill out the evaluation forms
that you got walking in it really helps us
inform our programs moving forward.
So thank you all so much and thank you all.
(audience applause)
- We should get a team evaluation form
for our employers so we know how to (laughs)
so we could have rigged the system.
Make sure you log out--
- Oh yeah that's good.
- Not just here but the settings over here.
Hi.
- [Woman] Congratulations.
- Thank you.
- [Woman] You guys did good.
Fifth year of learning.
- [Josef] Yeah, very busy year.
- [Woman] So, question for you, this is my student
by the way this is Kelsey.
- [All] Hi.
- [Woman] So my question is how can you get
a clinical psych student on your team?
- Yeah that's what I was thinking about.
- [Josef] Clinical psychology or?
- [Woman] Yes because I don't know if you all ran
into this with your patients but I know.
(crosstalk between students and audience)