As hospitals try to find ways to reduce the number of repeat emergency room visits and readmissions, UCLA Health is undertaking an emerging avenue of prevention: medical student “hotspotters.”
A group of medical student “hotspotters” and a physician from the David Geffen School of Medicine at UCLA huddle in a circle outside an apartment complex in Santa Monica as they discuss a few final details before preparing to go inside. This is not your typical doctor’s visit or rounding. It is a new kind of house call.
“We’re meeting the patient where she’s at,” reminds fourth-year medical and public health student Damond Ng, invoking the mantra of the hotspotters. Ng and four other students are waiting for Shebyon Bedgood, who is running a few minutes late from her nearby clinic appointment at UCLA Medical Center, Santa Monica. Ng, who also is copresident of the hotspotters, encouragingly guides the others under the watchful eye of Sun M. Yoo, MD (RES ’16), medical director of the Extensivist Program and Care Transitions for the UCLA Department of Medicine.
Ng mentions that the team should keep an eye out for a number of key factors that affect health, such as financial difficulties — explaining that low-income patients with diabetes have 25 percent higher admission rates at the end of the month than those with higher incomes — or depressive symptoms that could hamper medical compliance. “Let’s keep the antennae up for those,” he says as he glances at a checklist of questions. “But let’s make sure that our questions are open-ended.”
As hospitals try to find ways to reduce the number of repeat emergency room visits and readmissions, UCLA Health is undertaking an emerging avenue of prevention: medical student “hotspotters.” Now in its second year, the program’s student hotspotters already have improved health outcomes for participating patients.
The program, which originated in New Jersey as part of the Robert Wood Johnson/Camden Coalition of Healthcare Providers initiative and was adopted by the American Association of Medical Colleges, has expanded to include students from nursing, social work, pharmacy, public health, business and dentistry, as well as medicine. The students work in interdisciplinary “pods” of about five each and are assigned to a particular patient for six months, tracking care and going to homes to find social and safety determinants that may be missed in a typical office visit or hospital admission. Some hotspotters, such as dental and pharmacy students, will float between patients, as needed.
“By doing home visits, the hotspotters can bring so much more clarity to situations than patients might volunteer in an office visit, and in an abbreviated amount of time,” says David Hubley, a clinical social worker for UCLA Health outpatient services.
Currently, students volunteer in the program outside of their formal medical training, but leaders of the David Geffen School of Medicine at UCLA are working to have it be an official part of the curriculum, which would make UCLA one of just a very few institutions to do so.
“I absolutely believe that when people say things like ‘high utilizer’ or ‘frequent flier’ — names that frustrate medical staff [and are common labels for frequent emergency department visitors] — it implies that it’s the patient’s fault,” says Dr. Yoo, who helped to launch and who runs the program. “In actuality, it shows the vulnerabilities and holes in the system. We have developed a curriculum to teach students about social determinants of health, how to work in teams, leadership training, how to conduct home visits and how to think outside the box, as we often are taking care of patients for whom the system has failed or been inadequate.”
Top: Shebyon Bedgood during a home visit from the hotspotters team. Second: First-year medical student Kenneth Hahn (left) checks his patient’s blood pressure under the watchful eye of Dr. Sun M. Yoo. Second: The hotspotters program often provides students with their first clinical experience. Third: USC pharmacy student and member of the hotspotters team Alaina Austed, who is completing a rotation at UCLA, sorts through hundreds of medication bottles during a home visit as UCLA medical student Kenneth Hahn observes. Austed discards medications that are expired, duplicates or no longer needed. Making sure that patients keep on top of their medication schedule is a key way for hotspotters to help prevent emergency department visits.Fourth: Fourth-year medical student Jennifer Cohenmehr listens for a bruit, or vascular murmur, to check how patient Hector Jimenez’s dialysis fistula is functioning. Bottom: Hector Jimenez, who has been on dialysis for 33 years and has suffered two strokes, proudly shows off his “soul survivor” tattoo to his hotspotters team. Home visits allow for a greater personal connection between patients and their medical care providers.
SHEBYON BEDGOOD HAS HAD MORE HOSPITAL VISITS THAN SHE CARES TO REMEMBER. Diagnosed as a child with juvenile diabetes, the 49-year-old received a kidney transplant as an adult and later developed repeated urinary tract infections. Afflicted with night blindness as a result of diabetic retinopathy, she had fallen down a flight of stairs in her apartment and suffered injuries leading to a sepsis infection and subsequent partial toe amputation. Last year, she was diagnosed with breast cancer; after surgery, radiation and chemotherapy, she now is in remission. And earlier this year, her mother died.
Bedgood was identified as a candidate for the hotspotters team. She goes to about 10-to-15 medical appointments per month and takes about 25 required medications every day. Prior to being in the program, she went to the emergency room on a monthly basis, with some hospital admissions lasting for weeks. But for the past 12 months, she has had just two admissions.
“Before coming to UCLA and this program,” she says, her voice cracking slightly, “I really didn’t think I would be here now.”
Inside her home, Bedgood and the hotspotters sit down on comfortable sofas, introduce themselves and exchange pleasantries before beginning to assess how best to help Bedgood continue with her care. Her dog barks loudly at every passerby but already seems smitten with the hotspotters.
Each of the team members, in an organic yet considered fashion, asks Bedgood a series of questions. The inquiries are designed to learn not just about Bedgood’s medical needs, but also about her personally.
She had, at one time, worked at the VA, and she also ran a catering business. She switched insurance plans, and now premiums are more manageable. Her daughter used to live next door with her children, but recently she moved away, and Bedgood has felt a bit more isolated.
Bedgood is from the South, and she loves to cook and used to invite neighbors over for barbecues. But in Santa Monica, she was surprised when wary neighbors questioned her invitation to come over for dinner. Her mother’s death has profoundly affected her, and she has slipped behind a little on plans to take some classes to create more of a local social network. Despite everything, her attitude has remained positive. And she is joyful to have the hotspotters there.
There is one thing that is causing her some anxiety: the number of medications she has in her home. A little while later, Bedgood retreats upstairs to her bedroom with hotspotters in tow to bring out her numerous medications, which she begins piling onto her bed. While she does this, some hotspotters survey her living arrangements. There are a few red flags. The lighting on the staircase is poor, especially for someone with night blindness and a history of falls. There is no shower chair or slip-proof mat in the bath. There are unsecured throw rugs in precarious spots, including ones at the foot of her bed and at the top of the stairs. These are things the hotspotters will bring up with her and make recommendations, Ng says quietly.
The medications are gathered and brought downstairs and, after some 30 minutes of sorting and organizing, expired medications, duplicates and those that are no longer necessary are removed in a black trash bag to be disposed of properly. Bedgood is delighted to see the reduction.
“You can take the whole lot of ’em!” she exclaims, with a laugh. Alaina Austed, a fourth-year pharmacy student at USC who is completing a rotation at UCLA, promises to create a comprehensive list for her, and the team adds a note to provide Bedgood with better storage boxes.
As the medications are sorted, Kelly Verzthum, a third-year UCLA dental student, asks Bedgood some questions about her oral health. Satisfied that her patient is getting the proper dental care (including orthodontia), Vertzthum recommends an over-the-counter rinse to address Bedgood’s dry mouth, a side-effect from the oral chemo medication. “I didn’t realize the connection,” Bedgood says. “I will try that right away.”
Next, the students address some of the potential hazards that they identified. Bedgood says that her brother-in-law will help with the stairway lights. It had never occurred to her that the loose throw rugs might be a potential safety issue. “I just thought they were cute,” she says. “It’s such a simple thing to do. I will remove them.” As for the shower chair, she says she has wanted one for some time but hasn’t gotten around to it. The hotspotters take note — they subsequently provide one to her through a small discretionary fund set up to help with such needs.
When it comes time to say good-bye, there are hugs. “The visit went very well,” Ng says later. “We didn’t just start off with ‘these are your health concerns;’ we took time to get to know her, especially since she had just lost her mom. We didn’t want to overwhelm her. And she even expressed at the end that having the company is a part of the program that she particularly enjoys.”
THE HOTSPOTTERS ARE THE STUDENT ARM OF UCLA HEALTH’S EXTENSIVIST PROGRAM, a hybrid inpatient-outpatient program for complex patients. It was launched by Dr. Yoo in July 2017, with support from the Department of Medicine.
Candidates are selected for the program, using an algorithm developed by UCLA’s population health team that considers diagnoses, age, geography and other factors to identify patients who are at highest risk for hospital admission. Many of these patients have had two or more hospitalizations or four or more emergency department visits in the prior year. The program’s most common diagnoses include congestive heart failure, advanced cancer, history of organ transplantation and end-stage renal disease. But there are numerous other complex conditions. The ages of patients range from 18 to 101, with the average patient in his or her 60s.
In less than two years, the Extensivist Program has seen more than 400 patients. Indications are that not only is it working, it is working well. A study of the first 150 patients — comparing the six months prior to enrollment to the six months after enrollment — shows a 69 percent decrease in hospitalizations and a 67 percent decrease in emergency department visits.
“The preliminary data are quite remarkable,”Alan Fogelman, MD’66 (RES ’68, ’71; FEL ’73), chair of the Department of Medicine, says.
The team is not only tracking utilization, but also quality of life, patient satisfaction, access and disease-specific quality metrics. “We are strong believers in a ‘quadruple aim,’” Dr. Yoo says. This includes the Institute of Healthcare Improvement’s triple aim of improving population health, per capita cost and patient experience, as well as provider satisfaction. The additional data still are being compiled and analyzed, but anecdotal patient feedback so far has been overwhelmingly positive, Dr. Fogelman says.
“With each step of building our program, we have asked ourselves: ‘Is this the type of program we would want our family members to be taken care of in?’ This has always kept us on track,” Dr. Yoo says.
“It is great that we are seeing a decrease in utilization from a system standpoint,” she continues. “But as a primary care physician and extensivist, my highest priority is to improve the quality of care for my patients. I want my patients to be able to feel better, know they are supported and be able to spend more meaningful time at home with their families.”
IN ADDITION TO DR. YOO, THE HOTSPOTTERS TEAM INCLUDES William Carroll, MD; Yihan Chen, MD(RES ’17); Shanon Peter, MD; Nathan Samras, MD; and geriatric pharmacist Grace Cheng. Each mentors and oversees a pod of student hotspotters, with the exception of Cheng, who consults across the groups as needed.
Drs. Peter and Samras both were trained by Jeffrey Brenner, MD — the MacArthur “genius” recipient who founded the Camden Coalition — when they attended Robert Wood Johnson Medical School in New Jersey. Dr. Brenner pioneered the notion of extensivists (also known by other terms, including comprehensivists and complex-care physicians) and of student hotspotters as a way to try to help heal a fractured national healthcare system and address the needs of complex patients, who often are dealing with a combination of medical, social and mental health issues.
Dr. Brenner believes that innovation in education is required to get medical students working together to care for these most complex patients and keep them from falling through the cracks. Students, he says, are hungry for such innovation. “With the hotspotters movement, students are voting with their feet,” Dr. Brenner says. “They would like to learn to work in teams and to learn a new and different approach to working with patients. The last generation created student-run clinics, and that was quite successful. This is the next wave of the movement.”
In some instances, Dr. Brenner says, students are far ahead of the schools where they are training. “They have seen patients who have been mistreated, and they have had enough and want to roll up their sleeves and do a better job for their patients by working through a bigger lens,” he says.
Jennifer Cohenmehr is one such student. A fourth-year medical and public health student, Cohenmehr has volunteered with the student-run UCLA Mobile Clinic Project, which serves the homeless population on the streets of Hollywood, and she is copresident of the UCLA hotspotters. Many of the people she met on the street “have had encounters where they experienced discrimination or negativity from the health care system,” she says. “I’ve always felt that the bigger goal was to get these individuals plugged into the larger continuum of care.”
Clarence H. Braddock III, MD, MPH, vice dean for education and chief medical education officer at the David Geffen School of Medicine at UCLA, is an avid supporter of the hotspotters program, and he is working to scale up the initiative to become part of the school’s formal curriculum. “It’s a win-win,” Dr. Braddock says. “It is a win for the health care system to extend its reach into patients’ homes and community, and it is a win for trainees in that it’s a way for them to do something deeply meaningful early in medical school and to practice their craft in a way that includes authentic responsibility and real care of a patient.”
Kathleen Noonan, current CEO of the Camden Coalition, hopes that other schools will follow the lead of institutions like UCLA. “It is our goal that, at some point, enough schools will have this as a standard part of their curriculum for their medical students, as well as for students in other health-related programs such as social work, nursing and physical therapy,” she says. “It gives students tools and a framework for dealing with society’s toughest medical issues — a blueprint for complex care.”
IN GRANADA HILLS, MEMBERS OF ANOTHER HOTSPOTTERS TEAM, with Dr. Chen, visit Hector Jimenez. Jimenez has been on dialysis for 33 years, since he was 11 years old. He also suffers from anxiety and panic attacks. It took some gentle encouragement to convince Jimenez to join the program. When the hotspotters paid their first visit, he was in a highly emotional state; his wife, who also must undergo dialysis, was hospitalized with a serious intestinal infection.
But this visit is different. With his wife Anali now recovered and back home, Jimenez is all smiles when he comes outside to greet the hotspotters. Gathered around the kitchen table of his father’s home, where he and his wife live, Jimenez opens up to the team. They learn that he and Anali met at a UCLA dialysis unit and that it took him five years to ask her out; that the pediatric patients he regularly took out to lunch after their dialysis treatment dubbed him Superman; that he had worked as an insurance broker until he became too ill to continue. He has suffered two strokes, and he was put into a medically induced coma for 15 days. Thankfully, he says, he has no lingering effects. During that difficult time, a friend dubbed him “Soul Survivor,” which Jimenez later had tattooed on his arm so he never would forget his will to survive.
During the previous visit, the hotspotters talked with Jimenez about his receiving dental work. Today, his chief medical complaint is tingling in his arms and fingertips, a fairly new development. Dr. Chen and hotspotter Cohenmehr perform a Spurling’s test on his head and neck to check for radicular pain. Subsequent imaging tests will be scheduled to try to identify the cause of the sensation.
At the end of the visit, there are, again, hugs all around. “I am so grateful to Dr. Chen and to this program,” Jimenez says. “There was a time I thought this was it for me and that I would die. Faith and family are key. And I know UCLA Health is No. 1 on the West Coast, but for me it’s No. 1 in the world.”
PATIENTS CYCLE IN AND OUT OF THE HOTSPOTTERS PROGRAM. There currently are five active patients with corresponding medical pods, but Dr. Yoo and the other extensivists hope they will be able to increase the number of students who participate as word of mouth about the program spreads. The more students who sign up, the more patients they can enroll.
Beyond the benefits that such a program can deliver to patients, Dr. Braddock sees its potential as a balm for the growing issue of physician burnout. “Doing things in your work or during your training that have deep meaning can be a powerful antidote to burnout,” he says.
For Cohenmehr, her home visit with Jimenez stands out as a defining moment. “This is what medicine is all about,” she says. “This is why I went to medical school. It’s something very special, and I hope I can incorporate that in my career.”
Marina Dundjerski is a frequent contributor to U Magazine and the author of UCLA: The First Century.