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Results of an RCT of the coalition’s ‘hot spotting’ approach resulted in some reevaluation.
About a month before COVID-19 began sweeping across the country, the results of an important study of a program — designed to address the needs of patients who are high utilizers of the healthcare system — were published in the New England Journal of Medicine. Sometimes called frequent fliers, these high utilizers tend to have multiple chronic conditions, make frequent visits to the emergency department and get admitted to the hospital often. They constitute about 5% of patients but account for about 50% of total costs, according to the federal Agency for Healthcare Research and Quality. “Hot spotting” programs, which would find ways to intervene before the high utilizers’ healthcare problems became so regular, serious and expensive, hold a lot of appeal and make common sense.
The NEJM study was supported by the Abdul Latif Jameel Poverty Action Lab (J-PAL), a research organization at the Massachusetts Institute of Technology whose founders shared the Nobel Memorial Prize in Economic Sciences in 2019. J-Pal has pioneered the use of randomized controlled trials (RCTs) to test the effectiveness of health, economic and social programs; its findings have upended prevailing beliefs more than once. The results from this particular study showed that a hot spotting program in Camden, New Jersey, that had been praised by Atul Gawande, M.D., among others, did not reduce hospital readmissions. Although hospital readmissions were 40% lower among the patients in the program, the decline was nearly the same among patients in the control group.
When the results were published in the Jan. 9, 2020, issue of the prestigious medical journal, Kathleen Noonan, CEO of the Camden Coalition of Healthcare Providers, the group running the program, told The New York Times, “We’re disappointed by the results.” Noonan added that treating such patients with effectivity “is very, very hard work.”
Now, more than a half a year later, Camden Coalition officials say they have made adjustments to their program as a result of the RCT. “The Camden Coalition adapted its care intervention throughout the RCT and continues to do so based on what we learned since then,” Noonan says. “We found early on that we need to focus on cultivating deeper partnerships with social service organizations and launching programs that look beyond healthcare to get at the root causes of poor health outcomes.”
Since 2003, when Jeffrey Brenner, M.D., founded the coalition, the staff has recognized that these patients need primary care, social services, housing, food and, in some cases, a lawyer. “During the course of the RCT, we started programs in response to the overwhelming need we saw on the ground for things like housing and legal support,” says Noonan, pointing to the 7-Day Pledge, a citywide program that aims to get patients a primary care appointment within seven days after they have been discharged.
Noonan summarized what coalition leaders and staff have learned about patients with high utilization patterns:
Implementing these solutions is difficult in a healthcare system built to provide episodic care in which emergency rooms or urgent care centers may do little more than “treat and street.” Instead, almost all these patients need seamlessly integrated care in which anyone with high needs can get treatment tailored to his or her specific health and social-service needs. Getting funding for this care is a barrier to developing systems for these patients because it costs more than usual care.
Other challenges loom, ones that are beyond the easy reach of the healthcare system, Noonan says. “We must acknowledge how the issues of racism, poverty and the disinvestment in many urban areas underlie our patients’ challenges,” she says. “Without major financial and political investments in addressing those issues, any intervention will have limited impact.”
Despite these hurdles, Noonan says the coalition will continue to apply lessons learned from the RCT.
“Our next steps are to continue to adapt and test programs that aim to reduce utilization of the health system (and) also to achieve our broader goals concerning quality of life for these patients, self-advocacy and other patient-identified goals.
“It’s clear that there is still so much to learn,” she notes. “We will, as we did all along, look to the data for additional insights and listen to our community and front-line staff in order to evolve our programs.”
Joseph Burns is an independent journalist in Massachusetts who writes about healthcare.