1

Student Hotspotting Experience

Catalina Frau and Edsaida Ortiz from Ponce Health Sciences University, Ponce PR

Background

Primary Care Progress, the Camden Coalition of Health Care Providers and AAMC awarded twenty medical schools around the nations to participate in the Student Hot Spotting Initiative.

Participating Schools

➢ Cleveland Clinic/Case Western

➢ John Hopkins University➢ SUNY Buffalo➢ University Of Washington ➢ LSU/Tulane/Xavier➢ PSU ➢ Ponce Health Sciences

University ➢ Thomas Jefferson

➢ University of California-San Diego

➢ UMass➢ UNC – Chapel Hill➢ UNC- Charlotte ➢ University Of Chicago➢ University of Minnesota➢ University Of Rochester➢ Vanderbilt➢ VCU

To establish relationship among healthcare professionals to provide better services for patients, and promote Primary Care within the student community.

Mission

Team

Com

pone

nts • Public Health Student:1

Catalina Frau Kimberly Feliberti Edsaida Ortiz Elisadel Figueroa, MD Janette Ortiz

Medicine Medicine Psychology Public Health Nursing

Malynie Blanco, MD

Faculty Advisor Social Worker Nurse

Andres Lebrón, MSW Luz Suarez, RN BSN

Mentors:

Objective #1: Learn How to Work in an Interdisciplinary Team

Objective #2: Learn Motivational Interviewing Skills and Practice Compassionate Listening

Objective #3: Learn the Importance of Primary Care

Objective #4: Learn to Navigate the Healthcare System.

Super-utilizer Enrollment Criteria ➢ 2 or more admission in the past 6 months

➢ 2 or more chronic conditions

➢ Patient taking 5 or more medications

➢ Difficulty assessing healthcare services

➢ Lack of social support at home or in the community

Our Patient’s Story

➢ 30 y/o Hispanic male

➢ Past medical history: • Paraplegia • Uncontrolled DM type II• Recurrent complicated UTI’s • Pressure ulcers • Major depression

➢ Hospital admission: 2 hospitalizations the past 6 months

➢ Medications: 6 medications

➢Social History: • Lives with parents• High school education level• Limited income.

➢Health Insurance: Plan de Salud del Gobierno de PR

➢L e g a l S t a t u s : H o u s e confinement

Our Patient’s Story

Patient’s Residence

Intervention Strategies➢ Weekly Phone Calls

➢ Frequent home visits

➢ Patient Education

➢ Homework assignments

➢ Interaction with family members and caretakers

Enrollment

• Bedside triage

• Qualification

Home Visit 1

• Initial Interview • Assessment of:

• Medical needs • Psychological

state • Living condition

Home Visit 2

• Diabetes education

• Motivational talk

• Medication reconciliation

Home Visit 3

• Delivered urinary catheter

• Review insulin regimen

• Prepare for PCP visit

Intervention Summary

Home Visit 4

• PCP Visit Summary

• Issues addressed: • Legal status • Compliance • Foley status

• Patient agreed to psychologic intervention

Interventions by Social Media

• Helped patient established rapport with PCP

• Explored insurance coverage for Nutritionist and Psych Evaluation

Home Visit 5

• Delivered glucometer strips

• Reviewed lab results

Home Visit 6

Intervention Summary

Utilization and Claims Data

0

8

15

23

30

Apr-15 Jul/22-August/14 Dec-15

Inpatient

C6 months Pre-Enrollment

Charges: $46,340.71 Inpatient days: 48 ER: 1

Post- Enrollment Charges: $0.00

Inpatient: 0 ER:0

Leng

th o

f Sta

y

Lessons Learned➢ Back-up plan➢ Scheduling and communication ➢ Importance of transition of care process➢ Patient rapport takes time➢ Social determinants affect access to proper healthcare➢ High utilizations costs can occur despite having care➢ Patient Education ➢ Teach back method to ensure understanding

What is our NEXT STEP?

Spread the knowledge

Main Lesson Everyone has a story to tell.

Thank you