By Mark Couch
(December 2015) An internship program designed by a University of Colorado emergency medicine physician helped more than 3,500 patients address their health needs this past summer and offers a model for improvements that could help the nation’s healthcare system save money.
The Student Hot Spotters were a crew of about 20 undergraduates, recent college graduates and graduate students who worked last summer in the emergency department of University of Colorado Hospital on the Anschutz Medical Campus. They were available 24/7 for seven weeks in the emergency department to help patients with follow-up care needs.
“What we did is a health screening where they asked patients about food insecurity, housing insecurity, insurance, their primary care provider,” says Roberta Capp, MD, MPH, assistant professor of emergency medicine and designer of the program.
“They looked up on the Medicaid website to see whether patients had active Medicaid, whether they were part of the Accountable Care Collaborative program or not and then, depending on their answers, the health screening tool that we developed would tell them what to do.
“If the person said they went hungry for a number of days in a month, they would provide them with food pantry services,” Capp says. “If they said homelessness, the Hot Spotter would connect them with homeless resources. If they said no primary care provider, we would find them a primary care provider and then get them that appointment.”
The service provided by the Hot Spotters made a difference to the care that could be offered in the emergency department.
“The hard part for us is that we don’t have time to sit there and talk about what are the issues and what are the barriers,” says Alexander Ebinger, MD, assistant professor of emergency medicine and attending physician in the emergency department. “Is it that you don’t have a ride, or that you don’t know who to call to get an appointment?” The Hot Spotters were able to address those concerns.
“They were always there saying, ‘Who can I help?’” says Ebinger. “‘Can I go see this person and talk to them?’ So they were pretty proactive. In the event I needed one of them, I would just ask, ‘Would you mind seeing a patient and seeing if you can help them get a primary care appointment?’”
The Hot Spotters made getting primary care easier for the patients.
“They got so in tune with the patients and having patients go home with a primary care doctor appointment in their hand was mind-blowing to me as an ER nurse,” said Sandra Fogel, RN, who served as liaison between the Student Hot Spotters and the Emergency Department.
“I’ve done this for almost 15 years and you see cases where we have to tell patients, ‘We didn’t see anything, but if your pain persists, follow up with your primary care doctor.’
“And we know that’s not going to happen because they don’t have a primary care doctor and if they call, the appointment is going to be one to two months away. During the time when the students were here, patients would go home with an appointment the following week, if not the following couple of days, and that was amazing.”
And the service made a difference in the community.
Rich McLean, a leader with Together Colorado and a board member of Aurora Health Access, says: “Often when you go to the emergency room, you get some instructions and it’s over and done. And those instructions may or may not get done. This is revolutionary for our community because it’s not over and done. It’s changing a lot of lives.”
The program started in summer 2014 with a smaller group of interns and an all-volunteer cast of support.
“That first year was really great,” Capp says. “We reached out to about 650 people and they were only here from 9 to 5 Monday through Sunday for about seven weeks. The students went to do a home visits, I went on a home visit with the fire department. It was super educational.”
In this year’s class, the Hot Spotters spent a full day during the first week of the internship on a community bus tour to understand the needs of patients from their point of view.
“We did a whole community tour that lasted for about 10 hours,” says Capp. “We stopped at all the different organizations in the areas that we thought were hotspots for patients. We went to the food pantry, we went to Arapahoe House, which is a detox center, we went to Aurora Mental Health Center, a crisis center, the homeless shelter, Comitis, we went to the local FQHC (federally qualified health center) clinic in the area that takes a lot of Medicaid patients. We went to the Asia Pacific Center, we went to community health centers that held community activities for people. So they really had an idea it’s located here. This is what they can do for you. It’s not abstract.”
The Hot Spotters also scouted for clinics who would be willing and able to take new Medicaid patients.
“One of their first assignments was to do a scavenger hunt of primary care clinics that took patients with Medicaid and no insurance,” says Capp. “And the team that got the most clinics would then get a prize. They were supposed to take pictures in front of every single clinic that went to and they could only find clinics in Aurora because most of our patients come from here or Denver. It was really eye-opening.” It was also practical because they could put those findings to good use.
“We put all of their information together and created an online map they could then use to find clinics for patients,” says Capp. “When they started they knew which clinics they could go to and they knew where the person lived, so they could put in their address and it would pop out what clinic and what days and how long it would take to be seen.”
For Capp, the program is a professional accomplishment that draws from personal experience.
“I was born and raised in Brazil and I moved to the States when I was 14 turning 15,” Capp says. “It was just my mom, my sister and I and we were pretty poor when we moved here. We moved into an empty one-bedroom apartment and we slept on the floor. We all three worked as housekeepers. We started basically from scratch, so those times really resonate with me as I’ve gone through living the real American dream.”
Capp graduated magna cum laude from the University of Colorado-Boulder in 2003 with a BS in molecular, cellular and developmental biology and earned an MD from Harvard Medical School in 2007.
“As I went through school I realized that there are lot of health care access issues that those who live in poverty have to face and it’s not just health care access,” Capp says. “If you don’t have food on the table, that’s going to be your No. 1 priority. If you don’t have a place to live, that’s going to be your No. 1 priority. So it’s not just a prescription that you end up giving the person, it’s understanding where they’re at and how can you get them to that next step. “
Still, medical training doesn’t prepare physicians to help patients facing such challenges.
“That’s what really takes time and a lot of effort and it’s outside of what you learn in medical school,” Capp says. “And we’re never really taught how to address those situations, what do you do. It’s all been pushed toward the public health system when at the end of the day, health is not just about the prescription or health care access, it’s about everything.”
As a fellow at Yale University, Capp was part of the Robert Wood Johnson Clinical Scholars Program and there she focused on “services research,” searching for ways to improve care delivery.
“This is revolutionary for our community because it’s not over and done. It’s changing a lot of lives.”
The Student Hot Spotters toured the community to understand the needs of patients from their point of view.
A virtue of the Student Hot Spotters program was that it offered a model that could be deployed quickly in other locations, says Jennifer Wiler, MD, MBA, associate professor and vice chair of emergency medicine at the School of Medicine and adjunct associate professor at the University of Colorado Denver Business School.
“It was an opportunity to demonstrate that high-utilization patients could benefit from care coordination from interprofessional teams,” says Wiler, who helped Capp build the Emergency Department infrastructure for the Student Hot Spotters program. “And we could quickly train people from disparate backgrounds in an effective and cost-effective way.”
The Student Hot Spotters program complemented another initiative, called Bridges to Care, aimed at helping high-utilizing patients of the emergency department in Aurora find primary care that would be cost effective and more appropriate for those with longer-term, chronic health needs.
The Bridges to Care project is modeled on an effort developed by Jeffrey Brenner, MD, in Camden, N.J. It is funded primarily by the Center for Medicare and Medicaid Innovation to test whether the processes pioneered by Brenner can be applied in other locations.
Some patients who rely on emergency departments for care have needs beyond the immediate medical issue that brings them to the emergency department. Some have mental-health needs or substance-abuse problems. Others lack insurance or need housing and food. And while the treatment needs can vary widely, the payment system for emergency care doesn’t compensate staff for assisting patients with such needs.
On a panel sponsored by the Brookings Institution last spring, Wiler reported that the Bridges to Care program has shown some signs of success, with 550 patients enrolled since 2012. Six months after a Bridges to Care intervention, about 90 percent of the patients seek primary care services, rather than emergency department/inpatient care, for their health-care needs. This assistance helps reduce emergency department and inpatient visits by these patients and, according to Wiler, showed a $2 million cost savings to the health care system.
Still, the Bridges to Care program is aimed at a group of patients who frequently rely on emergency departments to provide care that could be provided by a primary care practice. The Student Hot Spotters was intended to catch all who need support, not just those considered “high utilizers.”
“The students are reaching out to all patients because you don’t have to wait until they come in three times to help them,” Capp says. “You should be able to help them the first time so you don’t have so many who are here two or three times. So the dream program would really be to replicate this not just with students, but with staff, 24/7 in the emergency department, to be able to provide these services and to help save a substantial amount of money.”