2017 Public Health Grand Rounds 05/05

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

- Morning everybody, good afternoon.
It's afternoon everybody.
Thanks for coming to Public Health Grand Round.
As you can see, this is our last Public Health Grand Round,
so this is it.
So we really appreciate your support this semester.
It's been really a great year.
(microphone feedback blaring)
Thank you.
I'm loud anyways, so that would've been bad.
So, thank you for coming today.
We have Public Health Grand Rounds here
to really highlight programs and research
within the institution that cross
between academic medical science and the community,
and how the two intersect,
and to really highlight initiatives that we have going
that cross those lines effectively and successfully.
And today is no exception,
we have a wonderful speaker today.
Public Health Grand Rounds are brought to you
by the Public Health Sciences Department
along with the Center for Community Health.
We work collaboratively to bring you the series.
We really think long and hard
about who we're bringing to speak at the series.
So we give you evaluation forms so that
you can write your suggestions for future speakers,
and if you think of any throughout the summer.
feel free to email me or Public Health Sciences Department,
and we're happy to see what we can do to get your topics.
Or if you know of a great speaker that you think
would be appropriate for this venue, let us know as well.
So today we have Dr. Stephanie Nothelle
speaking with us today.
Stephanie is a post doctorate fellow in geriatric medicine
at Johns Hopkins University, and serves as a member
of the national coaching and training team
at Primary Care Progress.
Following completion of her undergrad studies
at Case Western Reserve University and
medical training at Indiana University School of Medicine,
she pursued primary care internal medicine.
As chief resident at Johns Hopkins Bayfield Medical Center,
she was an integral part of the Bayview patient connection,
a resident led hotspotting initiative.
And we have hotspotting here for the third year
at University of Rochester,
so we brought Stephanie in as an expert in the field
to talk about her experiences.
For the past three years, she has been a project adviser
for the student hotspotting initiative,
sponsored by the AAMC, the Camden Coalition, and PCP,
and Stephanie recently co-authored a book chapter
about high cost, high need Medicare patients.
In her spare time she enjoys running,
watching British comedies, and anything with chocolate.
So near and dear to my heart for sure.
So join me in welcoming Stephanie today.
(audience applauding)
- Thank you.
Okay.
Okay, thank you.
I'm just going to switch over to my slides.
Okay, great.
So thank you Theresa, for that wonderful introduction.
Can everybody hear me okay?
As a geriatrician I tend to have a loud voice.
I'll try to keep it down with the mic though.
So I'm Steph Nothelle, I'm a postdoc fellow,
as Theresa said, in geriatric medicine.
And I am leading the student hotspotting team
at Johns Hopkins for the fourth year now.
During that time I've become involved
with both Primary Care Progress and Camden Coalition,
and you see both of their logos on the screen,
they're both sponsors of the
student hotspotting initiative.
So I helped develop and deliver some of the curriculum
for the National Learning Collaborative.
How many people have heard
of student hotspotting before today?
Okay.
Fair number.
Today I will review the basics
of what student hotspotting is,
but I also hope to show you that student hotspotting
is filling a really large gap
that we have in health professional's curricula,
and I feel that it is equipping the next generation
of healthcare providers to really
have the skills that they need
to improve the healthcare system
for some of our most vulnerable patients.
Just so I have a feel for who's in the room,
because I heard there's a pretty diverse audience
at these Grand Rounds, raise your hand if you're a student.
Awesome.
Raise your hand if you're not a student
but not a faculty member,
so you're like a postdoc or a resident.
Great.
And raise your hand if you're a faculty or staff member.
Great.
And how many people work clinically?
Okay, so a fair number, great.
Thank you.
So I hope this will be a fun talk.
As a postdoc, I don't really have any real disclosures,
but I believe in complete transparency
so I do get some consulting fees from Primary Care Progress
and the Camden Coalition for the work that I do with them.
And then my training is sponsored
by the Health Resources Services Administration,
the Geriatrics Workforce Enhancement Program.
I hope it'll be renewed.
It's up for renewal.
So we'll see.
How did I get here today?
Why am I a postdoctoral fellow talking to all of you
at Public Health Grand Rounds?
So my story begins I think where
probably a lot of your stories begin,
when I was thinking about what I wanted to do with my life,
which I still think about because I'm still not really sure,
I knew one thing, right?
I wanted to make a difference.
And I think we all want to make a difference, right?
That's why we get out of bed every day.
So in my late teens, early 20s,
I knew that I wanted to make a difference.
I liked science, I liked people, I wanted to help people,
this is the basic formula
that goes into every personal statement
that medical students write.
So I took the path of pursuing medicine.
And so, after four years of medical school,
and a lot of debt,
I found myself spending a lot of time in a hospital, right?
I knew that I wanted to do outpatient medicine.
I knew that I wanted to take care of older adults.
But graduate medical education in this country
is primarily in the hospital,
so that's where I was spending a lot of my time.
And this is where I started to wonder
if I was really achieving what I set out to achieve.
Right?
Was I really making a difference.
So for example, there is a patient
that everyone in my residency knew about.
He is a gentleman in his 40s, he had really severe diabetes,
and he was always in the hospital with
a severe complication of diabetes known as DKA,
or diabetic ketoacidosis.
So we would admit him to the hospital,
we'd often have to triage him to the intensive care unit,
he'd stay for a week, we'd discharge him
after we had fixed the problem,
and a week later he'd be back again, right?
And we'd go through the same thing again,
and again, and again.
And I just really started to wonder,
what are we doing, right?
I did this to make a difference.
Am I really making a difference?
And so I felt a little bit like this man.
Like I was just mopping and mopping and mopping and mopping,
when I really needed to figure out
how to turn off the faucet.
Right?
So luckily for me, I was at a residency program
with like-minded people.
And so there were some senior residents in my program
who had read this article.
Has anybody read this article?
If you haven't, it's a great read.
In case it's rainy this weekend, pick it up.
It's from an old issue of The New Yorker
written by Atul Gawande,
who is a pretty prolific physician writer.
And so, this article featured the work
of Dr. Jeffrey Brenner.
And Dr. Brenner is the family physician
in Camden, New Jersey.
He started the Camden Coalition of Healthcare Providers
and what Dr. Brenner was realizing was that there were
a not insignificant number of patients
like that patient I was just telling you about,
the patient with diabetes.
People who had really complicated medical illness,
really complicated social lives,
and as a consequence they were seeking healthcare
again and again and again.
And this population was getting a lot of attention,
because although they were small, right, they were mighty.
So I'm sure you've all seen some version
of this slide before, right?
This comes from the Camden Coalition,
that 1% of patients account 26% of costs.
10%, 73% of costs.
So certainly this population had the attention
of policymakers, of insurers, of health administrators,
and clinicians saw them a lot.
So they seemed like a lot more than 10% to clinicians.
So what Dr. Brenner was doing to address this population,
is he was identifying these high cost, high needs patients
using data, real-time data from the local Camden hospitals.
And when he identified those
that were utilizing the most care,
he would send out a team
to meet the patient in the community.
And he didn't send out a team of a cardiologist,
a nephrologist, a pulmonologist, right?
He sent out a team of a community health worker,
a behavioral health coach, you know,
all of the other health professions
that really add so much value to healthcare.
And these health professionals would
get to know the patient as a person.
Help identify what barriers they had, what goals they had,
and then help them overcome some of those barriers
and reach some of those goals.
And he saw that he was able
to decrease admissions pretty significantly
focusing on things like transportation,
housing, access to food.
So when the residents read this article
they thought well, we take care of a lot of patients
just like this in our residency clinic.
So why don't we do something similar?
So that was where the Bayview Patient Connection was born.
And so each incoming resident, of which I was one,
was paired up with a high cost, high needs patient
in our primary care clinic.
They were able to get a grant to fund a nurse case manager,
so we had access to case management services.
We were scheduled to see the patient every six weeks
for a longer visit instead of the traditional 20 minutes.
And we started off our relationship with a home visit.
As a geriatrician I love home visits.
So this is where I met Mr. B.
This is not actually the street he lives in,
but a pretty typical picture of Baltimore row homes.
If you haven't been, awesome.
So Mr. B.
Before I went on the home visit,
I looked through the chart, right?
It was really more scrolling through the chart
since we no longer have paper charts.
And I learned that he was an older man, in his 70s.
He had a laundry list of chronic medical problems.
The most severe of which were chronic lung disease,
for which he wore oxygen.
And he had chronic abdominal pain from chronic pancreatitis
that developed as a result of years of alcoholism.
And you know, when I read through his chart
I saw the words manipulative, drug-seeking,
non-adherent again and again
in discharge summary after discharge summary,
of which there were plenty of, right?
It seemed like he really spent a lot more time
in the hospital than he ever did at home.
So I started to get this picture in my mind
of what to expect, and I felt like
it was kind of a tall order, right?
How was I, a brand new physician,
going to help someone who didn't seem
very interested in helping himself?
But I was an obedient young intern
and I went on my home visit with my attending,
and I remember being really nervous
as I walked up to the door, and I knocked.
And he opened the door and he was
wearing Batman pajama bottoms.
And I was like this is gonna be great.
And he was wearing his oxygen tubing,
and he had the longest cord of oxygen tubing
I think I have ever seen.
It went all through his house.
So he welcomed us in, and I remember looking around
and thinking are we in the right spot?
There was this sign on the wall that said welcome home
and it was hand-painted,
and it looked just like one that my mom had painted
that hung in my Midwestern home growing up.
And the whole first floor,
it smelled like apple cinnamon potpourri.
I was like wow, I had the wrong picture in mind.
So he led us to the kitchen, we sat down at the table
and we drank some iced tea,
and he just started to tell us about his life.
And he told us about the really good times
when he was living in Florida
with his wife and his four sons.
And then he also told us about the not-so-good times,
when they moved to Baltimore for work,
and then he lost his wife and two of his sons to suicide.
And then he described just losing control.
And the only way he could numb the pain
was by drinking and taking drugs.
He just completely lost control.
Now, he assured me, this has been decades,
this has been years, everything is under control.
I'm much better now, but the hospital still labels me.
So I remember leaving that day and being really angry.
I was angry at myself for painting the wrong picture,
and I was really angry at the healthcare system.
Because they had completely misunderstood this man.
Or quite frankly, I didn't think
that they understood him at all
because no one had taken the time to listen to his story.
Our relationship continued.
He was to be my primary care patient,
and at first, things went smoothly.
And then we hit some bumps.
So he would have me paged again and again
asking for increases of his opioids.
So he was on opioids for the chronic abdominal pain
I was telling you about.
And I would just kept saying, you know,
let's talk about your breathing.
You know, let's talk about your kidney numbers.
I didn't want to talk about this,
because I didn't want to give him more opioids.
But eventually it got to a point where he ran out early,
lost his prescription, and I had to talk to him
and say look, you know I'm worried.
I'm worried that you have a problem with these medications.
I'd like to help.
I can refer you to methadone,
I can refer you to buprenorphine,
but I think you need help.
He of course, vehemently denied this.
Everything was fine, how could I do that,
oh my gosh, I'm just like the rest of them.
And I wondered if I was just like the rest of them,
but I felt like that was what I needed to do
to keep him safe.
So I prescribed him a taper.
And a week later I got paged by the emergency department
that he was in the emergency department in withdrawal.
He had mismanaged the taper.
So walk down in the emergency department,
and I was feeling like a total failure, right?
This was supposed to be my opportunity
to make a difference, right?
To keep someone out of the hospital,
and now he's in the emergency department, you know?
What am I doing?
Where are we going here?
So at first he didn't want to talk to me,
but he let me sit in his little room, so I sat in the room.
And after five or 10 minutes I looked over,
and I saw that he was crying.
And I walked over to comfort him,
and he said, "Look, you're right.
"I have a problem, I want help."
So I thought, great.
And over the next several weeks
with the help of a lot of people
we were able to get him into a methadone program.
But it, I learned, wasn't actually that easy, right?
First we had to find a methadone program
in his area that was accepting new patients,
then we had to try to find a way to get him there.
So we found a Medicaid taxi,
but the Medicaid taxi wasn't very reliable.
So on several occasions it left him there
and he ran out of oxygen before they came back.
So sometimes the solution isn't always as rosy as it seems.
But eventually we worked it all out.
He had a stable relationship with his methadone program
and his hospital admissions dropped.
So that happened, right?
Did he just manipulate me that first time I met him?
Did he sweet-talk me into thinking
that he was misunderstood,
and he really needed pain medications?
I don't think so.
I think that I was starting to see
what Atul Gawande wrote about in his article
and what Dr. Brenner was working on,
which is that these patients that are in the hospital
again and again and again,
we're just seeing snapshots of their lives, right?
And we're focusing on the breathing
and on the lab values, and those are important,
but no one's taking a step back
to look at the whole picture.
To look at what's actually driving the admissions.
And once I was able to see that whole picture,
it was clear as day, right?
He was misusing substances,
and when he did that he wasn't
taking care of his other chronic medical problems
and he'd end up in the hospital, right?
But why was that so hard to see?
The healthcare system just wasn't set up
for me to really get to know him as a person,
but rather see him in these little episodes of care.
So I like to think of this,
this getting the whole picture as patient-centered care.
There's a lot of different definitions
of patient-centered care,
but at the residency program I trained at,
patient-centered care was getting to know
the patient as a person.
And this data actually comes from a program at my residency.
And it shows that patient-centered care
isn't just some nice notion that we like to talk about,
but there's actually a reason why we should do it.
So in this internal medicine residency training program,
the program directors created
a separate inpatient wards team.
So a team of residents who would take care of patients
when they were admitted to the hospital.
The team would have a lower census,
meaning they took care of fewer patients,
and then they were charged with
getting to know those patients as people.
So there was a structured curriculum
around the conversations you were supposed
to have with patients.
What is your life like outside of the hospital?
Who are your sources of support?
And then after discharge you would do a home visit
to see how things went.
So they looked at patients with heart failure,
heart failure is a chronic condition
known for frequent readmissions,
who were cared for either on the intervention team
that I was just talking about,
or on standard teaching teams within the same hospital,
same residency program.
And this graph is a little bit of a double negative,
but what they saw is that your probability
of not being readmitted,
or your probability of staying out of the hospital
was higher if you were cared for by the intervention team
than if you were cared for by the standard teaching team.
Pretty powerful stuff.
That team still exists at my residency.
So reflecting on all of this and my experience with Mr. B,
I came to the conclusion that in medicine,
we're really just skimming the surface of people's lives.
And for some of the patients,
particularly the high cost, high needs patients,
we really need to take a deeper dive, right?
Because when we skim the surface we're again,
just focusing on the lab values, the list of symptoms,
how to keep someone out of the hospital,
and we aren't focusing on those other things
that are just as important as medicine.
Like access to care, referral to mental health services,
stable housing, domestic violence.
And Mr. B taught me that taking that deeper dive
is very emotionally challenging at times,
but it's so worth it, right?
It's the only way that we can help some of these patients.
Because each time they're accessing care,
it's like a cry for help,
but the healthcare system isn't set up
to identify the help that they need or actually deliver it.
This made, this experience made it very, very easy for me
when I got an email about the
student hop spotting collaborative to say yes please.
Like, sign me up.
And so I started a team at Johns Hopkins,
and we've been going strong ever since.
So the student hotspotting collaborative
is a six month program.
It occurs every year.
And it is co-sponsored by all of these
wonderful institutions listed here.
Any school, any health profession school
in the country can apply.
The requirements are to have a team of four to six students
from at least two health profession schools,
any health profession that you can think of.
You need to have a faculty member
from each profession represented,
and then a licensed clinical social worker.
Because he or she is really going
to be the star of the team.
Once schools apply and are accepted,
they commit to working with high cost, high needs patients
at their local institution for six months.
The program contains four key elements, right?
The first element is an in-person kickoff event.
That has traditionally occurred in Camden, New Jersey.
At the kickoff event, students learn some basics
about hotspotting,
and some basics about leadership and teamwork,
and then they go back to their own institutions.
Once they're back at their own institutions,
they have access to an asynchronous curriculum.
This just means that the curriculum
is divided up into chunks,
there are videos and online modules online
that students can access when they need them.
So if they're seeing a patient with severe depression,
they could click on the video
about talking to someone about mental health disorders.
In addition, there are monthly skills labs.
So these are also all electronic
through like a video conferencing
where students have the chance to practice with each other
some of the important skills that they learn.
Like how do I actually talk to a patient
for the first time about this project?
How do I explain it to them?
How do I do motivational interviewing?
What do I do when the project's over?
How do I tell them that I'm no longer
going to be coming to see them?
And then the final component is case conferencing.
So this again is an electronic video webinar format
where teams have the opportunity to present a patient
who they're taking care of to a whole variety of experts.
Some are physicians, some are nurses,
some are social workers, who have experience
taking care of this population.
And then in the end after six months,
there's an in-person wrap-up where there's an opportunity
for reflection, for a celebration,
and for a little bit more learning
about teamwork and leadership.
So the actual intervention has five parts.
The first part is identifying patients.
So the way that this is done in Camden traditionally
has been through a health information exchange.
Where Dr. Brenner and his team are able to get realtime data
about who's being admitted to the hospital when.
Not everybody has those where they live,
and just because you have one,
doesn't mean that you can access it
or use it for this purpose.
So there have been a variety of different ways
students have identified patients.
Students sometimes go to the inpatient hospital teams.
I know that that's what's done here,
and that can be really successful.
Case managers on the inpatient floors can say,
oh, I know just the patient for you.
You know, Mr. Smith, he keeps coming back again and again.
And the student can meet the patient right there
and have that first face-to-face contact.
The way that we did it this last year,
we used to do it that first way by going to the hospital,
this last year we got a list
of some of the highest cost patients
from our local Medicaid provider,
and we would just cold call patients.
That also ended up working, so lots of different ways.
Some faculty members recruit patients
from their own practice.
There's no set requirement for how you have to do that.
So once you identify the patient,
you have to engage the patient, right?
The goal with a six-month program
is to kind of find that sweet spot
of a high cost, high needs patient.
Some patients we know are high cost high needs
because it's the end of life.
We're probably not going to make a difference
in utilization there.
Some patients are high cost, high needs
because they have cancer.
That's also difficult for a six month intervention
with students, and some of them are high cost, high needs
because they have a lot of chronic conditions,
and they have complicated social lives.
And that's what we're looking for.
Patients are approached, told about the program,
that it's six months,
and that we don't provide any medical care,
but we simply help coordinate care and support them.
So most teams try to recruit about two or three patients
for the six month period.
And once they've identified the patients,
the first step is learning the story, right?
So taking that deeper dive,
because that's what lets you figure out
how to turn off the faucet, right?
Students are encouraged to do a home visit
and to really get to know what that patient's life is like.
What their experiences are, who supports them,
what barriers they face.
In learning the story, Camden teaches them
a number of different techniques,
like backwards planning,
and I'm happy to go into detail about any of these things
if anyone's interested.
But the idea is to identify a patient's goal.
What are they motivated to do?
And then do what you need to do
to help them get there the best you can.
So sometimes that's coordinating care,
the patient's confused,
my primary care doctor told me not to take this medicine,
my lung doctor told me to take this medicine,
what am I supposed to do?
Sometimes it's the coordination.
Sometimes it's just support.
Social isolation can be pretty powerful,
and having someone there to support you
can make a huge difference.
And sometimes it's education.
You know, we throw a lot of information at patients
and expect them just to learn it.
It took me four years of medical school
and three years of residency and I'm still learning,
so I'm not sure how I expect my patient to learn
at the end of the 20 minute visit.
So the students do a lot around education as well.
The key is they do not provide any medical care,
they basically just support, support, support.
By the end of the six months, the patients graduate.
Now there's different models of how to do this.
The way that we have done this,
and the idea of graduating the patient I should say
is that student hotspotting
is a short time commitment, right, six months.
And the idea behind the Camden Coalition
is not that you are getting a health buddy for life, right?
The goal is somewhat like home nursing
for those of you who are familiar with home nursing.
When I was a resident I thought home nursing
was just this service that would come forever
and take care of things for the patient.
No, no, no, no.
Home nursing is there to educate the patient
and the caregiver to take care of themselves, right?
And so that is the same goal that we have here.
We're not trying to be an endless source of support,
but we're trying to educate and empower and connect
so that when we leave, the patient is on stable footing.
So we've partnered with our local
Medicaid organization at home,
and so when we graduate we transition those patients
to one of their case management programs.
Because things come up even if they're stable when we leave.
Life is complicated and they should have a point of contact.
Okay.
I told you all that I was going to tell you
how this fills a gap in the curriculum,
and how it trains the next generation
of healthcare providers, so how does this all add up?
This is an abacus in case you're wondering what it is.
Because I think that the parts,
the sum of all of the parts of hotspotting
are much greater than just simple arithmetic
would lead you to believe.
So I want to spend the rest of the talk talking about this,
and I'm going to break it into three main areas.
So there's three topics or content areas that I think
students who participate in student hotspotting
have the opportunity to learn about
that are missing from traditional medical curricula,
and that most people don't learn
until they start to practice medicine.
So this first one is probably very familiar
to people in public health, right?
Medical care does not equal health.
Health is not merely the absence of disease.
This is not something that is stressed very much
in health professionals training schools
outside of public health.
And you know, if medical care did equal health,
then one might think that the area around,
I am not that familiar with Rochester,
this is my first time here.
You have a beautiful campus.
I haven't ventured much beyond the campus,
so I'm gonna use my home institution as an example.
So has anybody been to Baltimore?
Seen Johns Hopkins Hospital?
Okay, great.
So if medical care equaled health,
the neighborhood around Johns Hopkins Hospital,
which by the way is called Middle East,
it would be really healthy, right?
Those people have access to one of the best
healthcare institutions right in their own backyard.
But people who have been there,
did it seem like the healthiest neighborhood in Baltimore?
No.
The life expectancy at birth in that neighborhood
is far below the life expectancy at birth
in many of the other neighborhoods in Baltimore.
So it's not just access to care, right?
and the way that this plays out in student hotspotting
is a couple years ago we had a patient on the team
who lived right in that neighborhood.
She lived a couple blocks away from Johns Hopkins Hospital.
And she had a primary care doctor,
a cardiologist, an endocrinologist,
a nephrologist all within walking distance of her house.
Right?
But she had all those doctors
because she had severe heart disease,
she had terrible diabetes, she had bad kidney disease,
and so she was in the hospital at least every other month.
So when I asked the medical students
at the end of the intervention,
what sense do you make of that?
She has these four amazing clinicians, right?
She is blocks away, she can see the building.
Why is she in the hospital so much?
And the student said, "Well, you know, it's complicated."
She has low income, she's on disability, right?
And so after she pays her rent and her utilities,
she can't afford all of her meds,
let alone healthy food that she should be eating
for her diabetes and heart disease.
She has poor vision and low literacy,
so she can't understand the instructions
that are sent home with her.
And even though she's blocks away,
she has terrible wounds on her legs,
and so she can't walk to the hospital.
She doesn't have a car.
And so a lot of times she just can't make it there
unless she calls 911
and ends up in the emergency department.
So medical care very clearly does not equal health.
So while the students learn this qualitatively,
like I just described, I thought it would be kind of fun,
I showed this to all the students.
The CDC has actually tried to quantify health.
Okay, has anybody seen this before?
Okay.
So I want you to think about these four factors
that are listed here.
Physical environment, clinical care, socio-economic factors
and health behaviors, and then try to match them
to a quadrant of the pie chart.
Okay, so let's get some answers.
Physical environment, what do you think
the correlating percentages for contribution to health?
Shout it out.
- [Audience] 30.
- I hear 30 and 20.
Okay.
clinical care.
- [Audience] 10.
- Wow, that's always 10.
So cool.
Socioeconomic factors.
- [Audience] 40.
- 40, wow.
And health behaviors.
- [Audience] 20.
- Okay.
20, 30, okay.
So let's see how you did.
You ready?
Huh, surprising right?
So physical environment only 10%.
Clinical care 20, health behaviors 30,
socio-economic factors 40.
Now the way they determines this
is there's a lot of methodology that I did not dive into,
but epidemiologists at CDC who I respect very much, right?
They're epidemiologist at CDC.
They used the data from,
Robert Wood Johnson Foundation has this great website
called CountyHealthRankings.gov,
and so they pulled all of the data from that website
to break it down into rough percentages.
Now I show this chart not because
I want people to memorize it,
I don't want the students to memorize it.
Also sometimes showing this chart
leads to a conversation about who's really responsible
for the different chunks of the pie chart.
We won't have that discussion today.
But I think regardless of what the answers
are to those questions, it's important to know
that these different pieces of the pie exist, right?
And that if we said theoretically
that clinicians are responsible for clinical care
and maybe they could make an impact on health behaviors,
right, we're supposed to coach people on health behaviors.
That's only half of the puzzle, right?
And so I think that that is an important thing
that every health professional should learn.
I never learned it in medical school,
and that hotspotting really brings to life.
Now the one thing about medical care
not equaling health that the pie chart doesn't capture,
but I think is a key learning from student hotspotting,
is that we operate in an incredibly complicated
healthcare system, right?
My dad just recently had some medical problems.
They live in rural Indiana,
and I consider myself pretty savvy
about the healthcare system, right?
I've been there for you know, six years.
And I had a heck of a time trying to navigate with him.
You know, try to get him the right care.
So in student hotspotting one of the ways
that I've seen the students learn about this
is a couple years ago we had a patient
who had sickle cell disease,
and she had a number of complications
of her sickle cell disease.
She grew up in Baltimore,
got care at our sickle cell clinic,
but then she found a partner,
they moved outside of the city,
they got a home actually just right over the county line
where things were affordable and safe.
So then she tries to access transportation
to make it to her hematology appointment.
No, sorry, your transportation isn't coming.
Well, she had no idea why, she called the students.
The students tried to figure it out.
It took the students several phone calls
and several days to learn that her funding
for her transportation was tied to where she lived.
She had moved over the county line,
and therefore there was no more transportation.
Because, sorry, no, can't cross that street.
Sorry.
How is she supposed to know that, right?
And I think if it takes really intelligent
health professional students several phone calls
and several days to figure it out, that's a problem, right?
So we don't necessarily have the answers to the problems
at the end of student hotspotting,
but I think it's really eye-opening
that so many different complications can arise.
So the next big thing that students
who do the student hotspotting project
have an opportunity to learn
is about leadership and followership.
So in addition to the curriculum around
how to identify and work with high cost, high needs patients
Primary Care Progress also provides a curriculum
around leadership and teamwork.
And the particular model of teamwork, or I'm sorry,
of leadership that they teach is relational leadership.
Has anyone heard of relational leadership before?
Yeah, all right, great.
So what relational leadership says,
and I'm grossly oversimplifying here,
is that there are many models of leadership, right?
And in healthcare we traditionally focus on
what and how, right?
We have 50 patients to see in the clinic this afternoon,
how are we going to do that?
You're going to check them in,
you're going to get the vitals,
you're going to do this, right?
We're very task oriented.
And what relational leadership says is
that is great, that is very important, right?
But what we need to add to that
is a focus on the who, right?
Who are those people?
What motivates them?
And most importantly, what are the relationships
between the people and how do those different tasks
impact that relationship,
or make the most of that relationship?
And there are four main components of relational leadership.
One is managing self, right?
We are a who that comes to the team.
We need to know what skills we're bringing
and kind of what our tendencies are.
Fostering teamwork, right?
A natural extension of teams and relationships.
And then the bottom two are coaching and mentoring,
which can mean coaching and mentoring peers and/or patients.
And then accelerate change, which touches a bit on advocacy.
Now I think that in student hotspotting
we really focus most on the top two quadrants
that are blue and green.
So I want to take a minute to talk
a little bit more about those.
But since we're in the afternoon
and I know people might be getting sleepy,
I'm going to ask for some audience participation.
So, when you think about the traditional healthcare team,
who is leading it?
Doctor, right?
Yeah, so our current team model looks like this.
Doctor is the dot in the middle.
And how do you think the people who are the arrows feel?
Do they feel empowered and valued?
No, they're a step down from the doctor, right?
And how efficient do you think this is?
Not efficient.
There's a reason why people say if you want something done
don't give it to a doctor, right?
Because everything bottlenecks at the doctor,
the doctor doesn't do any of it.
And I feel okay saying that because I am a doctor.
So, sorry the other doctors out there.
What relational leadership says is
a more ideal team model is like a snowflake.
So the snowflake model is an interdependent group
working around a common goal, right, the patient.
And the power is decentralized.
The power is spread out, right?
So a key part to making this work is mutual respect
and valuing the other members of the care team.
So for example, after the students learned about this
what they decided to do was rotate roles.
So everybody gets a chance to lead a team meeting.
Everyone gets a chance to present a patient.
Just because I'm the medical student
or I'm the clinical person on the team
doesn't mean that I have more power than you.
And the reason that this is so important
and the reason why I added followership
is I saw this article recently in the New York Times
and it just like, made my day.
This is not hard data,
I know this is Public health Grand Rounds,
but Susan Cain points out in this article
that in higher education we are super focused on leadership.
What are your leadership skills, you know?
We write essays for admission,
you're always trying to describe yourself as a leader.
But for that model to work, for that snowflake model to work
you can't just lead all the time,
sometimes you have to take a step back
and you have to follow, right?
If my patient needs to fill out an application
for section 8 housing,
I am not the person to come to, right?
I don't know where to find that application.
I don't know where to turn it in.
I'm probably going to fill it out wrong.
I need to hand that over to someone
who knows how to do that, which might be the social worker.
Right?
She can take the lead with that one.
So when we talk about teaming,
I just wanted to bring up one more point.
Anybody play with Playmobil when they were little?
Yeah, I was totally tickled when I saw this.
You know, I've heard people say,
we're smart, we don't need to learn how to work in teams.
Right?
Do people think that they need to learn how to work in teams
or is that like kindergarten sharing, right?
My sister is a kindergarten teacher
and she'll tell you they don't all learn to share
by the end of the year.
The reason why it's so important to team
is that we do need to learn how to do this,
and there is actual evidence to show that this works.
So in surgery where it's a little bit easier to study
because it's one acute episode of the surgical intervention
and the team is well defined,
the VA did this study on 108 facilities.
74 of them the surgical teams received
intensive team training,
and then they measured surgical mortality
after each quarter of team training.
And you can see that from baseline
to those who made it through quarter four,
there was an 18% drop in surgical mortality.
Which was statistically significant with a p-value of 0.01.
The 34 facilities that did not receive the team training,
which are not pictured here,
but they were the comparison group,
they had a drop of 7% in surgical mortality,
but that decrease was not statistically significant.
The p-value was 0.59.
Now maybe this just works in surgery and not in primary care
because primary care is so messy, right?
But that's not true either.
So this article is really cool,
and they use social network analysis
which basically looks at how people are connected.
You fill out a survey, say I interact with this person
this many times a day.
And social network analysis basically produces two numbers.
One number is how connected you are,
and one number is how centralized the power is on the team.
So they did this in 31 primary care teams in Wisconsin
focusing on outcomes for patients
with cardiovascular disease.
And here were their results.
So they looked at blood pressure control,
LDL cholesterol, urgent care, ED visits,
hospital days and cost.
Top two rows are unadjusted model,
bottom two rows are adjusted model.
And they did like a generalized linear mixed methods model
to account for the clustering.
So I want to draw your attention to here,
so you can see in the adjusted model
as social network density, so that's the measure
of how connected your team members are,
as that went up, hospital days went down, right?
Relative risk is 0.62,
and that was statistically significant.
Cost also went down, right?
Those two things are very correlated.
And as social network centralization,
so the power is held by few people,
as that went up, hospital days went up
for these patients with cardiovascular disease.
So you know, these students
from all these different professions
who have an opportunity to work together
get to start to learn some of these things
before they're actually doing the surgery,
and before they're actually the primary care doc
taking care of the patient with cardiovascular disease.
My last point brings me back to the reason why
I think we all get out of bed in the morning, right?
We all want to make a difference.
And I really think that students
who do student hotspotting feel
that they can make a difference, because they really do.
So there's this team at Sutter Health in East Bay California
and at the end of their student hotspotting experience
they brought together a town hall
of their hospital administrators,
stakeholders in the community,
medical education curriculum designers and students.
And they had this huge town hall
on how can we better serve this population,
this high cost, high needs population.
Students did that, after this six month
student hotspotting project.
That's pretty awesome.
This is some data from our John Hopkins hotspotting team.
This is a patient who we took care of several years ago.
And there's number of visits
for months pre and post enrollment.
You can see ED visits were cut almost in half.
And office visits, which we want to go up, right?
We want to shift care to the appropriate setting,
they more than doubled.
Just to show you that this wasn't a one time thing,
this is data from this past year.
ED visits again, in blue dropped.
Hospital visits in orange also dropped.
And primary care visits went up.
What did the students do to make these changes?
It varies.
With this patient I honestly think
that they just supported him.
We were talking about this last night at dinner.
They were like, how did they do that?
I think he was really lonely
and they provided him with some support.
So the question is how to keep that going
after the students leave.
The other patient, she didn't have a primary care doctor
and she didn't understand how to go
to her primary care appointment.
So when she showed up with a student
for her primary care appointment,
they went through the whole appointment,
she got all the information, she went to check out,
and she looked at the student and said,
"I forgot, I have a breast lump.
"Was I supposed to bring that up?"
The student was like, "Yes!"
So the student was able to help the patient
make another appointment right then and there
so that she could get the care that she needed.
It did turn out that she had breast cancer,
but it was resectable.
You know, this is pretty amazing stuff.
I can't share the cost data with you,
so we partnered with our local
medicaid institution this year.
There's a fee to participate in
the National Learning Collaborative,
and I am a postdoc and I don't have
just like extra money sitting around.
So the Medicaid organization offered to pay for our
participation in the National Learning Collaborative.
They gave us their data,
and then they gave us their cost data,
and they said as long as you provide
a return on investment we will fund you.
We provided a 500% return on investment this year.
So they are going to continue to fund us.
So just imagine what students can do all across the country
to make a difference, to learn what they need to learn,
and to provide better care for patients
who really need the better care.
So, thank you very much.
And I'm happy to take questions.
About 10 minutes left.
(audience applauding)
Yeah?
(audience member speaking off mic)
Yeah, so I think the problem
with doing research on this population
is that the high cost, high needs population
is very heterogeneous, right?
So it is made up of some people who
will be high cost, high needs for one year
because they have a complicated orthopedic procedure
and have some complications or an ICU stay,
and then the next year they won't be.
So if you capture them, there's the regression to the mean.
Right?
There's also some people at the end of life,
and there's some people with substance abuse,
there's data that people who access the ED
and are high cost, high needs because they access the ED
are a different population than the people
who are high cost, high needs
because they access the hospital.
So I think that that is the biggest problem
with the evidence base.
A lot of the articles that I've read, you know,
I'm trying to start a research career in this field,
it's really tough because everyone
defines the group differently,
and I think that that's a problem, right?
Because there is not going to be
a one-size-fits-all intervention, right?
I think the population who's like dual diagnosis,
has psychiatric illness,
there is going to be a different answer for them
than those with substance abuse,
those who are elderly and homebound and socially isolated.
You know, I think we have yet to kind of shake it out.
So I'm confident that the evidence will improve when we
are able to target these interventions a little bit more.
So I think we were able to show data
because we had three people in six months,
and so we could dedicate a lot of time
to really figure out what they needed.
Whereas the VA had a larger volume.
Yeah?
(audience member speaking off mic)
Yeah, so that's a really big problem.
So this last year we connected
with our local Health Care for the Homeless,
because they have a case management program
for their high cost, high needs population.
So the patients that we were able to identify,
if they had a phone, that was really helpful.
The only other way we were able to identify them
is if they regularly came in
to Health Care for the Homeless for various things.
So sometimes there are social activities,
social events, meals, they would come in and the students
could have face-to-face time with them then.
But you're absolutely right,
they're really hard to get ahold of.
There was the patient a couple years ago who was homeless,
and who actually passed away during the intervention.
And the students just kind of knew where he hung out,
and so they would go to that general area.
But there's not a really good answer that I have for that.
It is a problem.
Yeah?
(audience member speaking off mic)
So how the information that,
like the barriers that we learn about,
how that all gets handed off?
Okay.
So what the students have done,
is they and have created this document, right?
That basically summarizes things
that they have identified our areas of need,
and what they've tried to overcome them.
So that document is given to the case manager,
then that's supplemented with one of two things.
Either if this works out,
which I think it works out less than half the time,
all three of them, the student,
or I guess all four of them because it's two students,
the patient, and the new case manager
meet together in person, so there's a warm handoff.
Or there's a phone call,
just to kind of pass along information.
That's what we try to do.
Yeah.
Still have four minutes.
I also answer questions about geriatrics.
(audience member speaking off mic)
No, we type it up.
Yeah, we don't put it in the EMR.
We keep all of our information,
our institution has this thing called JHBox,
which is a HIPAA secure Dropbox like thing,
so everyone can access the document.
That's where we keep it.
And so when we give it to the case manager,
we either invite her to have access to the box,
or send it securely.
If we add secure to our email it gets encrypted.
(audience member speaking off mic)
Oh I want it in the EMR.
I don't have the power to get it there.
So there was a lot of institutional concern
about this program and what it meant.
Liability concerns.
Basically that was a battle that I didn't fight
just to get the program up and running.
But I think that you're absolutely right.
And so the residency model of this
that I was talking about in the beginning,
that's still existing in some shape or form,
when they do the first home visit,
and the goal of the home visit's a purely social home visit
to get to know the patient as a person,
that gets documented in the electronic medical record.
But with the students,
'cause some of them are public health students,
they don't even have access to the EMR.
Yeah?
(audience member speaking off mic)
Yeah, so I think the students make good effort,
but as you might imagine, sometimes it's hard
to get ahold of a busy provider.
So the students try to go to office visits with the patient
and introduce themselves and what their role is there,
and then if possible,
if they're within the Johns Hopkins system,
they can email back and forth.
If they're outside we could do phone calls,
but it's been challenging.
We try to reach out to every outpatient provider
who has a longitudinal relationship with the patient,
but we're not always able to get a hold of them,
or if we do get a hold of them,
they're like who are you talking about?
You know?
So that kind of opens up a whole other issue.
But that's what we try to do.
- [Theresa] I just wanna give a shout out
to our hotspotting team.
Several members are in the room,
so thank you guys so much for you work on this.
And really the same challenges that Dr. Nothelle has,
we have here as well.
- Yeah.
Yeah, so you guys, I don't know if you know,
have an awesome team that's been going strong.
I still remember the first time University of Rochester
presented at the Wrap Up Conference,
and they had this awesome graph that showed like,
the utilization went like that, right?
They had helped a woman who couldn't access dialysis anymore
actually access a dialysis center,
and so she didn't have to go the emergency department
for her dialysis anymore.
Like, that's not rocket science right?
But it was amazing.
It was a really beautiful story.
So you guys are helping lead the way here.
- [Theresa] Dr. Alvarez And myself are the faculty advisors,
so if we have students that are interested...
(Theresa speaking of mic)
On the team next year, talk to any of us.
- Well, thank you for your attention.
I hope you have a wonderful weekend.
(audience applauding)
- [Theresa] Please pull out your evaluations on the way out.
We'll be lingering for a minute if you have any questions.
(audience murmuring)
- Oh, sure!
Thanks for coming.
- [Woman] I took down your email address.
- Oh good, yeah.
And I brought a card.
The corners might be a little bent,
because I'm not fancy enough yet
to have a business card holder.
- [Woman] Thank you so much, I really appreciate it.
- Nice to meet you.
(woman talking off mic)
Keep in touch, let me know how you're doing.
- [Woman] Thank you so much.
- Yeah.
(audience murmuring)
Hi. - Hi.
I'm Andrew. - Hi Andrew.
- Nice to meet you. - Nice to meet you too.
- [Andrew] This is a really great project.
- Oh, thank you.
(Andrew speaking off mic)
From the undergraduate?
Oh awesome, congratulations.
- [Andrew] Thank you, thank you.
(Andrew speaking off mic)
- Oh, cool.
(Andrew speaking off mic)
Yeah.
- [Andrew] And I'm looking for research assistant jobs
post college having to do with team-based healthcare.
- Yeah.