Grant Helps Students Address Health Care Super-Utilizers’ Needs

Katz and a team of three other University at Buffalo health sciences students received one of 20 national grants from the Association of American Medical Colleges, Primary Care Progress and the Camden Coalition of Healthcare Providers. 

The grants encourage student teams across the nation to develop innovative, local solutions to address the problems of health care super-utilizers — patients who frequently seek care in high-cost settings.

“Hot spotting” is the practice of identifying super-utilizers and developing interventions to better address their needs and more effectively provide care.

“A look at health care cost distribution reveals that a small fraction of the total population accounts for a disproportionately large share of total cost,” explains Katz, the team leader.

“In 2012, 5 percent of the population accounted for half of all health care expenditures, according to U.S. government figures. Often, visits to the emergency room and subsequent hospitalizations could have been avoided, but social and economic issues prevented these patients from receiving timely and cost-effective care,” he says. 

“At great expense to the system, these patients are cared for regularly in the hospital setting but their condition remains unchanged, and the cycle repeats.”

Hospital medicine is ill-equipped to meet the unique needs of these patients, Katz explains. “As doctors, we are trained to implement the most direct and generalizable interventions, which can render our care as somewhat generic and less than holistic. Success is dependent on inherent trust in medical providers, low complexity and relatively few adverse social determinants of health.”

The current approach has failed for super-utilizers, says Katz. “Despite having a seemingly constant presence in the hospital, these patients are chronically misunderstood.”

Katz and his team members deepened their understanding of super-utlizers’ challenges through their partnership with the Jericho Road Community Health Center in Buffalo, a federally qualified patient-centered medical home. 

Eighty percent of its patients are on Medicaid or are uninsured and have incomes at or below 200 percent of the federal poverty level.

Using electronic medical record data, including continuum of care records that reflect a patient’s utilization footprint, Katz and his collaborators identified four Jericho Road patients who qualify as super-utilizers.

The team worked closely with these patients to identify obstacles, establish goals of care and develop sustainable, cost-effective solutions. With guidance from the Camden Coalition, faculty advisers and support from Jericho Road providers, the student team generated and executed individualized care plans. 

They completed the project in January 2016. “Shortly following the wrap-up conference, we began meeting to discuss the second cohort and how to support the inclusion of a similarly structured program into the curriculum,” says Katz.

The learning collaborative — which included monthly webinars and case conferences, mentoring and a curriculum learning guide — was led by Jeffrey Brenner, MD, of the Camden Coalition of Healthcare Providers. Brenner coined and popularized the concept of hot spotting; he received a MacArthur “genius” grant to address the problem.

When Katz started clinical rotations as a third-year medical student, he quickly came to appreciate what Brenner had described.

“In my clinical rotations, I learned from and cared for a diverse population with complex social, psychological and physical needs. Often, I witnessed patients discharged with the unspoken expectation that they’d be returning shortly after; this unfortunate reality seemed unavoidable,” says Katz.

“The traditional structure of hospital-based care leaves providers out of touch with the challenges a patient faces in the community and unequipped with solutions. Only by stepping outside the clinic walls and into the lives of these individuals can one begin to appreciate the unique challenges.”

In previous work with Jericho Road and through the school of medicine’s chapter of Physicians for Human Rights, Katz has advocated for vulnerable populations. He is committed to primary care and is a Primary Career Track award winner and Primary Care Research Scholarship recipient at UB.

Ranjit Singh, MB BChir, clinical associate professor of family medicine and a faculty adviser on the project, notes that the team was comprised of “an energized and talented group of students” who “make a difference in the lives of a group of patients who have fallen through the cracks.”

The students modeled interprofessional teamwork that “rejects the current fragmented approaches and embraces the patient as a complex human being with dynamic challenges — such as transportation, housing, food security and other social needs — and helps in overcoming these challenges,” he says.

All students on the team have multidisciplinary experience in working on social justice and community service.

Team member Mallory Abdulla, from the School of Nursing, is focused on quality improvement emphasizing outcomes and efficiency. She has worked as a supportive case manager, mental health technician and supervisor of home care services.

Elizabeth Borngraber, from the School of Social Work, focuses on women’s health, health access and policy. Team member David Essi, from the School of Pharmacy and Pharmaceutical Sciences, has a master’s degree in bioethics. He attended an Epidemiology and Population Health Summer Institute at Columbia University.

In addition to Singh, other advisers on the project were:

• Charles Syms, clinical associate professor in the School of Social Work, who has extensive experience in addressing issues such as domestic violence, forensic mental health and substance use disorders
• Eleanor Nixon, a family nurse practitioner at Jericho Road, who specializes in managing high-risk patients requiring intensive needs assessment and comprehensive care coordination