Hotspotting medically complex at-risk patients in an urban primary care residency clinic

Presentation Notes

Presented at North American Primary Care Research Group 46th Annual Meeting; November 9-13, 2018; Chicago, IL.


Context: It has been established that 5% of the patients incur 50% of the health care cost. Hot spotting is the collaborative care approach put into place in the hopes of improving outcomes and decreasing healthcare costs.

Objective: Create a more formalized plan for managing medically complex patients within one family medicine residency clinic over one year.

Study Design: Prospective enrollment, retrospective review, quality improvement. Quarterly interdisciplinary team meetings were conducted throughout the year to discuss patients in order to analyze and address each patient’s social situation and barriers. At least one home visit was also conducted and more frequent contact was established with each patient. Setting: Milwaukee County, WI, USA.

Patients: Twenty medically at risk patients (mean age 62.4 years, 70% female).

Results: The average Charlson score for the patients was 6.2 (median 6; Note, a score of 6 equates to 10 year mortality risk of 98%). Analysis of characteristics of the 20 patients revealed 80% prevalence of mental illness and communication problems; 70% were over-medicated. After initiating the pilot, total ED visits decreased 20.0% (95 vs 76) and total admissions decreased 35.5% (31 vs 20) at Aurora hospitals. Surveys determined that patients, clinic staff, and physicians all were very satisfied with the intervention. Overall, 94% of provider respondents felt more patients would benefit from being involved. Total direct cost savings 6 months pre- and post-intervention revealed $187,000 savings for 17 patients ($11,000 per patient) and a 9:1 return on investment.

Conclusions: The impact of this project was profound. Given the ease at which it was incorporated into the practice, as well as the promising results of decreased ER visits and hospital admissions, this pilot successfully managed complex patients. We believe this concept has large potential to provide further benefit in the future and is worth duplicating.

Document Type

Oral/Podium Presentation

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