THE SUBJECTIVITY OF SUCCESS: RECOMMENDATIONS FOR THE EVALUATION OF STUDENT HOTSPOTTING

Healthcare spending in the United States remains heavily concentrated amongst a small group of patients: 5% of the population accounts for roughly 50% of annual expenditures and 1% of the population accounts for nearly a quarter of annual spending.¹ National programs have sought to reduce spending and improve healthcare quality by connecting high-need, high-cost (HNHC) patients to existing services within healthcare institutions and broader communities. The Camden Coalition of Healthcare Providers (CCHP) was a pioneer in identifying and working with HNHC patients. The CCHP coined the term hotspotting from using data-driven mapping techniques to visualize health care utilization “hot spots” ripe for intervention. They utilize admission data to identify patients who are HNHC and provide individualized, in-person support in navigating their complex medical and social needs.¹ Interprofessional teams are at the core of this program. These teams consist of doctors, nurses, anthropologists, social workers, medical assistants, and other professionals with the intention of integrating strengths and expertise from each professional’s training to provide a patient with high quality, holistic care. Hotspotters collaborate to connect patients with appropriate medical care, community organizations, and government programs in an effort to achieve patient care goals, improve overall health, and reduce excess healthcare utilization.¹ In 2013, CCHP partnered with the American Association of Medical Colleges and Primary Care Progress to bring hotspotting to students in different professional programs.² Student hotspotting has shown great promise as both a tool for interprofessional education as well as an innovative way to provide patients with support beyond the traditional healthcare system. Here, we describe our experiences running a multi-institutional interprofessional student hotspotting program, and offer suggestions for evaluating outcomes in student hotspotting and other programs designed to support HNHC patients.

Our own interprofessional hotspotting program, Atlanta Interprofessional Student Hotspotting (AISH), has been operational since 2017. AISH is student-run and based out of Grady Memorial Hospital, Atlanta’s public, safety-net hospital. We work with complex patients who may require intervention across multiple social and medical domains to improve their overall health and utilization of healthcare services. Our student members come from pharmacy, medical, nursing, social work, public health, and mental health counseling programs at academic institutions across the Atlanta metropolitan region. We leverage our skillsets by working in institutionally diverse, interprofessional teams to provide patient support and help address the complex social determinants of health of our patients via a nine-month partnership. Housing, food access, and transportation are among the top areas for support our patients identify.

While there is limited data regarding the effectiveness of hotspotting programs, a randomized control trial of the CCHP model found no significant effect on patient readmission rates after 180 days.¹ This study used quantitative, electronic health record-based metrics in evaluating hotspotting outcomes and program effectiveness. As noted by the authors, this study did not examine patients’ perceptions of healthcare use or other patient-reported benefits of the hotspotting intervention; however, we believe these metrics are critical to consider when evaluating the effectiveness and benefit of hotspotting programs.

An intervention’s “success” is subject to the biases of the evaluator, the metrics, and the demands of larger institutions, but it is important and relevant to tailor metrics so that they address the needs of the target population. In a patient-centered intervention, such as hotspotting, the metrics should reflect patient goals. This is in line with the Triple Aim objectives: improve patient care, improve the health of populations, and reduce the per capita cost of health care.³ At the core of the CCHP hotspotting framework and curricula are concepts such as empowerment, self-esteem, skill-building, social support, knowledge of and confidence with social services, and health literacy. Furthermore, assessing interprofessional collaboration merits an analytic toolbox that takes advantage of diverse approaches to research. For these reasons, we recommend that studies evaluating hotspotting programs expand the evaluation framework, rather than relying solely on quantitative data, and identify outcomes targeting patient perceptions and hotspotter growth as key metrics of success.

First, we suggest that studies evaluating hotspotting programs utilize a mixed methods approach to quantitatively analyze healthcare outcomes and qualitatively examine these outcomes from a patient perspective. Qualitative data is inherently hypothesis-generating. Incorporating it into the framework for program assessment will provide a richer picture of program efficacy and further contribute to the generation of future research. Adding open-ended questions to patient progress and outcome surveys becomes an opportunity to center interventions on patients’ needs, advancing the overall mission of a patient-centered program. In AISH’s program evaluation, for example, we will be collecting baseline and endpoint data on psychosocial self-efficacy of people living with diabetes using the 28-item Diabetes Empowerment Scale⁴ as well as collecting narrative feedback every two months about progress towards patient goals. We aim to elicit how our hotspotting intervention has impacted patients, including the effects on their therapeutic relationships with providers, understanding of their health conditions, and progress toward their overall healthcare goals. With this approach, patients have space to define their barriers and facilitators to health care and health outcomes that we may not have considered.

We further recommend that studies consider outcomes specifically related to the hotspotting members when defining program success—especially when evaluating student-run hotspotting programs. In this context, hotspotter skill-building is a key dimension of analysis. Proficiency in root cause analysis, community resource navigation, and interprofessional collaboration are unconventional, albeit relevant, variables to include in hotspotting program evaluation. Promoting interprofessional education (IPE) is an investment in the future of the public health and healthcare workforces and can influence team dynamics and performance. Monitoring these variables, especially with mixed methods, may offer a more meaningful description of a program’s success from a professional development perspective. To assess IPE, AISH will collect baseline and endpoint data using the IPE Collaborative Competency Self-Assessment.⁵ We also plan to conduct a focus group with graduating hotspotters at the end of our program year to better understand attitudes and perceptions of the AISH IPE curriculum. We hypothesize that understanding the breadth of this impact will strengthen the case for the value of hotspotting.

We recognize that AISH’s approach to implementation and evaluation may not apply to all hotspotting programs given our unique methodology and the student-driven nature of our program. However, incorporating mixed methods and redefining primary outcomes of success are the first steps to understanding the impact that hotspotting can truly have on a community. We believe that hotspotting is an effective community-based intervention best evaluated using an integrated approach to understand patient perspectives as well as hotspotter experiences as holistic measures of success.