BACKGROUND CONCEPTS WHAT IS HOT SPOTTING?

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1 LETTING GO

2 G N I T T O P S HOT ENT M T S E V IN N O N R U T E R R U VALIDATING O E G N A H C H G U O R H T G IN L L FREE CLINICS EXCE IO H O, N O T Y A D, H P M I, D R GLIA A G A R Y M & K C O L R E H S N DR. SHARO

3 BACKGROUND CONCEPTS WHAT IS HOT SPOTTING? Economists took the concept to beat competitors and prospered.. suburban to urban = growth IT- hot spots are a location of optimization for network connection Police took the concept in order to concentrate on reducing crime Healthcare took the concept to combat against high cost/high utilization When life for a patient is just a HOSPITALIZATION waiting to happen

4 ECONOMIST FORMULA Then develop a competitive strategy..using #3 Rules

5 RULE # 1 SHARPEN YOUR STRENGTH What is your team s relationship with vulnerable populations? -Can you impact change? -Can you grab attention? -Can you speak their language? -Can you make a difference? -Can you change behaviors? Surround yourself with exceptional people J J J J

6 RULE # 2 KNOW YOUR COLOR UNIQUE PERCEPTION UNIQUE SKILL SET UNIQUE ASSETS

7 RULE # 3 PARTNER WITH THE BEST NOTHING GREAT WAS EVER ACHIEVED ALONE. IT TAKES A TEAM OF SHARP PEOPLE TO COMBAT THE EVER-SHIFTING DEMANDS OF TODAY. SHARP PEOPLE KEEP OTHERS SHARP BE WARY OF THE PEOPLE WHO ARE BLIND TO YOUR SHARP STRENGTHS AS THEY WILL DRAW YOU AWAY FROM YOUR EDGE. FIND YOUR ACE ASSOCIATION AND LEAN IN.

8 HOT-SPOTTING = INNOVATIVE CM JUST HOW GOOD COULD YOU GET? HOW HIGH WILL YOU RISE? HOW MUCH IMPACT WILL YOU HAVE... Ref: Ryan Jenkins, Project Times, September 23,

9 JEFFREY BRENNER, MD FRONTLINE FILM: Doctor Hot Spots

10 RED LIGHT Acute Conditions: Post CVA, PE, Newly Diagnosed CA, New Diabetic Need to be ENGAGED so they don t return to hospital Chronic Conditions: Exacerbated Asthma, Uncontrolled Hypertension Need to be monitored to prevent further deterioration Pregnant Addiction Very Young Very Old Co-Morbidities Recent Return from Another Country Implementation into the real world, not all are able to be saved What are your RED Light Conditions for case management?

11 YELLOW LIGHT Multiple Risk Factors Alcohol/Drug Abuse History Chronic Hepatitis B-C Pregnant with Hx of Miscarriage Recently Moved to Area Pain without Etiology NES Smoker

12 GREEN LIGHT RX Refills are Due Not Picked Up Yet Lab Results Not Completed on Time Sutures Past Due for Removal Last Visit Elevated BP due to No Rx Slightly Abnormal Labs Potential Loss of Contact, Phone Not Taking Messages

13 SCENARIOS

14 PLAN To Communicate Do Resolve To Trend Narrate Collect DATA MINING 3-STEP OUTCOME To Adapt ACT

15 COLLECT TO TREND Reach Out Clinic Zip Code tracking for change Ranking Poverty from Highest to Lowest when compared to the state of OHIO Latino Asian African American Women Children LOCATE & READ Community Assessments

16 PARTICIPATION IN FEDERAL PROGRAMS COLLECT TO TREND POP: 11.5M POVERTY RATE DEMOGRAPHICS EMPLOYMENT EDUCATION ADULTS AND CHILDREN RECEIVING WELFARE (TANF): 144,691 CHILDREN RECEIVING FOOD STAMPS (SNAP): 734,000 EITC RECIPIENTS: 966,000 HOUSEHOLDS RECEIVING FEDERAL RENTAL ASSISTANCE: 224,564 FAMILIES RECEIVING CHILD CARE SUBSIDIES: 27,100 PARTICIPANTS IN ALL HEAD START PROGRAMS: 49,702 NUMBER OF CHILDREN ENROLLED IN MEDICAID AND CHIP: 1,685,004 NUMBER OF WOMEN AND CHILDREN RECEIVING WIC (WOMEN, INFANTS AND CHILDREN SUPPLEMENTAL NUTRITION PROGRAM): 263,683 HOUSEHOLDS RECEIVING LIHEAP (LOW INCOME HOME ENERGY ASSISTANCE PROGRAM): 459,286

17 COLLECT TO TREND CMS/FQHCRHC-REPORT_4/INDICATOR/REPORT

18 NARRATE TO COMMUNICATE BUILD CONCISE FACTS TELL COMPELLING STORIES RELATE IT TO PARTNERS NEED $7.00 or $70,000: transportation/hospitalization $4.00 or $4,000: Free Clinic Visit/ER Visit $25/hour or $15,000: Nurse CM/ER Visit Minimal Cost or Large loss: Free Clinic visit/hospitalization

19 RESOLVE TO ADAPT TRANSPORTATION TRANSLATION ENCOUNTERS PATIENT MAY NEED ACCESS TO AN APPOINTMENT, RECEPTIONIST NEEDS TO KNOW TRANSPORTATION IS BETTER IN THE MIDDLE OF THE DAY DON T ASK FAMILY TO ASSUME THE ROLE, ESTABLISH CONFERENCE PHONE SESSIONS OR MEDICAL INTERPRETERS TO GET THE STORY STRAIGHT ONE PHONE CALL WHAT IS YOUR BP OR BETTER YET, STOP BY AND WE WILL TAKE YOUR BP, OR CALL ME AFTER YOU GET IT TAKEN AT A LOCAL FIRE DEPT. CALL FREQUENTLY BUT NOT ENOUGH TO ANNOY ASK NOT WHEN DO YOU WANT YOUR NEXT APPT? ASK, WHEN CAN YOU GET TRANSPORTATION TO COME IN? TEXT/ AS OPTIONS BUT DO NOT SEND HIPAA INFORMATION, MERELY INSPIRE THEM TO CONTACT YOU OR TEXT REMINDERS