Hotspotting Education

Gayle Christiansen, MCPContent and Experience Curation

• Membership organization with 22-member board; incorporated non-profit• About 80 full-time staff• $9.02 million annual budget: Mix of foundation & federal grants, technical assistance & care coordination contracts, & hospital support

Overview of Camden Coalition

In Camden, 1% of the population accounts for30% of health care receipts

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OUTLIERS are patients are in the long tail of data

What problem are we trying to solve?

PoliceJail

The next generation: student hotspotters

VISIBLE CURRICULUM Build awareness, knowledge and skill

INVISIBLE CURRICULUM Build awareness, resiliency and skill

VISIBLE CURRICULUM Build awareness, knowledge and skill• Intervention models – COACH; patient stories• Care philosophies - Harm reduction; TIC• Engagement/coordination of community and

community of care providers• Effective teaming• Skills & techniques – Identifying & enrolling pts; MI

INVISIBLE CURRICULUM Build awareness, resiliency and skill• Psychological flexibility

• adapt to fluctuating situational demands• reconfigure mental resources• shift perspective• balance competing desires, needs, and life domains

• Acceptance/Problem-solving dialectic • Resist what is effectively resistible• Accept the unchangeable• Focus on effective action

• Emotion regulation/Distress tolerance• Tolerate what cannot be immediately influenced• Regulate difficult emotions so they can be channeled into

effective action

Transformative Learning:

“transforms problematic frames of reference to make them more inclusive, discriminating, reflective, open

and emotionally able to change”

(Mezirow, 2009, p.22)

• Experiencing a disorienting dilemma• Undergoing self-examination• Conducting a critical assessment of

internalized assumptions and feeling a sense of alienation from traditional social expectations

• Relating discontent to the similar experiences of others---recognizing that the problem is shared

• Exploring options for new ways of acting

• Building competence and self-confidence in new roles

• Planning a course of action• Acquiring the knowledge and skills

for implementing a new course of action

• Trying out new roles and assessing them

• Reintegrating into society with the other perspective

Mezirow (1975)

Stages of transformative learning experiences

Healthcare on the curveDenialTreat part of the patient--avoid ambiguous areasMake a protocol to avoid discomfort in lieu of addressing problemAvoid engagement/information (keep Pandora’s Box shut)

DefeatUnconsciously competentSwimming in your laneLimited problem-solvingDetached care

HostilityReactivity to patients/colleaguesPresent to polarize vs. problem-solveUncompromising rigidityContemptuous campaigning

BlameBlame patient, system, provider or workerLimited or no problem solving

• If I educate a patient enough they will follow the care plan

• My role with patients is to be a problem-solver to fix all their health problems

• I am competent when the patient makes the change I am suggesting

• If the patient goes to their appointments they will be healthy

• Our systems, when navigated correctly, can address patient complexity

• We have a social service safety net resourced to help people with their social needs

Myths debunked by confronting complexity

Moving through the curveDisorienting DilemmaUncovering complexityLearning patient’s storySeeing patient in home

Patient PresentationsWrap-up eventMaking a case for this work

Moving through the curveDisorienting DilemmaUncovering complexityLearning patient’s storySeeing patient in home Case Conferencing

Mosaic CurriculumTeaming

Case ConferencingMosaic CurriculumTeaming

Case ConferencingMosaic CurriculumTeaming

Preceptorship Approach

• Model unconditional positive regard

• Dispute the “fix-it” framework

• Promote reflective practice• Connect feedback to

curriculum content and use of tools/skills

• Recognize strengths and resiliency

• Acknowledge the difficulty of the work

• Model balance between curiosity and expert advice

• Use a change process framework

• Support coping and distress tolerance

• Anchor in the relationship

Camdenhealth.org/curriculum

Moving through the curveDisorienting DilemmaUncovering complexityLearning patient’s storySeeing patient in home

Patient PresentationsWrap-up eventMaking a case for this work

Case ConferencingMosaic CurriculumTeaming

Case ConferencingMosaic CurriculumTeaming

Case ConferencingMosaic CurriculumTeaming

Patient Presentations

Developments in the Works

Student Hotspotting Expansion

Complex.care

Health

Claims

Health Plan

EMS

Public

Census

Social Services

Housing

SNAP

Child Services

School Property

Law enforcement

Courts ParolePolice Corrections

Camden ARISEData included in Camden ARISE

Data not yet available

OverlappingPopulations

National Center for Complex Health and

Social Needs

Goals of a national center• Convene and connect those in the field

• Educate the workforce, both new and veteran

• Encourage new investment in programs

• Advocate for policy reform

• Encourage research and the development of an evidence base

National Center for Complex Health and Social Needs ConferenceThursday, Dec. 8 and Friday, Dec. 9Sheraton Society Hill, Philadelphia, PA

Discussion

Gayle Christiansene: gchristiansen@camdenhealth.orgw: www.camdenhealth.org

Your Turn

In small groups, choose one of the following to address. Include in your development how you will have others experience the importance of SDOH.

• Persuade the city to provide transportation to free clinics

• Write an op ed to your local newspaper• Persuade the CEO of your health system to address

neighborhood issues• Persuade a non-traditional partner to work with you• Other

Additional Slides

Spatial Analysis ofCamden Hospital

CostsSeveral buildings(e.g.) annually generate $1+ million in hospital costs.

6% of city blocks account for 18% of patients and 37% of receipts.

January 2002 – June 2008

Camden Coalition of Healthcare Providers

Theory of Change

Data

Inter

vent

ion P

arad

igms

Trad

itiona

l Med

icine

Diabetes Heart Failure COPD ESRD

Hotsp

ottin

g

Community-Based Multi-disciplinary Care Management for Vulnerable Populations

Triage

Bedside Engagement

Bedside Care Planning

Camden Coalition Care Plan Domains

Home Visits

Accompaniment to PCP

Graduation

• Acceptance frameworkUnconditional Positive Regard (Carl Rogers)EmpathyHarm reductionMotivational interviewing

• Trauma informed care• Holistic, patient-centered approach• COACH Framework

Therapeutic Relationships

The ACO

Camden Coalition ACO• 38,000 covered lives representing 95% of Camden’s Medicaid population• 15 primary care practices• 3 hospitals• 2 contracts with Medicaid managed care organizations

Traditional Response to Homelessness

Homeless

Shelter placement

Transitional housing

Permanent housing

Housing As Healthcare

Sam Tsemberis, Founder of Pathways

Success of Pathways to Housing

Dr. Tsemberis and the Pathways Program were able to demonstrate 85-90% housing retention, as compared to 60% or less in other models of supportive housing

WhyHousing First at the Camden Coalition?

Peter

Driving Diagnosis• COPD exacerbation

• Acute Asthma Exacerbation

• Hypertension

• GERD

Social Indicators • Experiencing homelessness (1+ year in shelter)

• Limited Income ($210/month)

• History of incarceration

• Limited Social Support

• Generalized Anxiety Disorder, Major Depressive Disorder

• In remission from Substance Disorder Dependence from Alcohol

Hospital Utilization• Frequent ED Visits• Frequent Inpatient Admissions to local hospitals

A Camden Partnership