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Student Hotspotting Experience
- 1. 1 Student Hotspotting Experience Catalina Frau and Edsaida Ortiz from Ponce Health Sciences University, Ponce PR
- 2. 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.
- 3. 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
- 4. To establish relationship among healthcare professionals to provide better services for patients, and promote Primary Care within the student community. Mission
- 5. TeamComponents • Public Health Student:1
- 6. 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:
- 7. Objective #1: Learn How to Work in an Interdisciplinary Team
- 8. Objective #2: Learn Motivational Interviewing Skills and Practice Compassionate Listening
- 9. Objective #3: Learn the Importance of Primary Care
- 10. Objective #4: Learn to Navigate the Healthcare System.
- 11. 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
- 12. 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
- 13. ➢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
- 15. Intervention Strategies ➢ Weekly Phone Calls ➢ Frequent home visits ➢ Patient Education ➢ Homework assignments ➢ Interaction with family members and caretakers
- 16. 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
- 17. 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
- 18. 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 LengthofStay
- 19. 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
- 20. What is our NEXT STEP?
- 22. Main Lesson Everyone has a story to tell.
- 23. Thank you