I walked out of my office just in time to watch D.M. pass out, falling backward off of the scale, narrowly missing my medical assistant. He had come to his primary care visit drunk and hypoglycemic again. I made changes to his medications and insulin, referred him to specialists, and had him see our nurse and behaviorist, whom he could only see once because he would not be able to afford her copayment.
At each subsequent visit, he was able to repeat all of our prescribed changes back to my nurse and me before he left the office to return to his life and world. He would then return for primary care follow-up after even more ER visits and hospital admissions and without having made any progress. We continued this trend for weeks and months until one day his death certificate arrived on my desk. I failed this patient. We failed this patient. Our system failed this patient.
At the time, I was practicing at a Philadelphia-based federally qualified health center, (FQHC) providing primary care for the sickest of the sick. I am an Adult Nurse Practitioner and, when I started to work at the FQHC, I was fresh out of graduate school with a decade’s worth of registered nursing experience. As time went on, I was expected to see more and more of these complex patients—many of whom didn’t speak English—and often waited too long to seek care.
As I pushed back on rising productivity expectations, administrators told me that if we went bankrupt and closed our doors, then no one else was going to help these patients. So I became a hamster on the wheel. I might have been keeping our clinic open, but I was not making a difference in the well-being of these patients. I would see one patient, make adjustments to medications, and they would return (maybe) without any discernible improvements to their health. This work was not fulfilling to me. When I walked in the door on Friday evenings, I’d say hello to my husband and then burst into tears—the release of tension from a frustrating week at work. And Monday, I would go get back on the hamster wheel.
The Hotspotting Fellowship
Then I learned about the Hotspotting Fellowship run by Dr. Jeff Brenner’s Camden Coalition of Healthcare Providers (The Coalition) and the Crozer-Keystone Family Medicine Residency Program in Springfield, Pennsylvania. Dr. Brenner developed a community-based care coordination model that provides quality care for high utilizers of emergency rooms and hospitals through a team-based approach—with the intent of keeping them out of emergency rooms and hospitals. Without a doubt, I knew this was the way that we need to practice medicine.
I got the fellowship, which is now coming to a close. Had I met D.M. during this program, I would have attempted to get to know who he really was and where he came from. I would have asked, “What happened to you?” and not “What is wrong with you?” I would have surrounded D.M. with a team to address the social and psychological issues that might be hindering his medical care and to work toward empowering him to take responsibility for his own care. He would be placed at the center of this care, and we would assist by breaking down barriers and providing him with solid relationships to help build his trust in the health system.
Over the last year, I have learned how to pool data and manage a super-utilizer intervention. I have been welcomed into C-suite meetings and negotiations with insurance companies in order to learn how to develop a successful hotspotting program for their beneficiaries. I have attended state legislative sessions to enact policies designed to break down the silos that intensify the need for a team-based approach. I have had the opportunity to travel to conferences around the country to present the data that we have been working on and to learn from and absorb the knowledge of others who are pushing the boundaries of our current practices.
But most importantly, I have spent my days working in interprofessional teams, providing high-touch, high-intensity care for these high-priority patients in their homes (or wherever they call home). Now, when a patient like D.M. walks into my office, I take a step back from the pressing issue, like uncontrolled diabetes, to look at him as a whole. Together with the patient, we try to get to the root of the issue—no refrigerator to keep insulin because the patient is homeless, for example—because that is likely the cause of the uncontrolled diabetes. Having the opportunity to visit the patient on his turf and to deploy a pharmacist or social worker to assist with needs that arise, this feels like real medicine.
The faculty and team at Crozer and the employees of the Camden Coalition have provided me with unbelievable opportunities. They have opened my eyes to the infinite possibilities that are available to aid patients in healing and growing. And for the first time in my practice, I have started to meet patients where they are, not where I am or where my studies tell me they should be. For the first time in my career, I am practicing common sense medicine and I am watching patients flourish.