Publication Date



at-risk patients, primary care, nursing, hot spotting, super-users, hospital admission, emergency department


Background: In the United States, 5% of patients incur 50% of health care costs. Hot spotting, a collaborative care approach, may improve patient outcomes and decrease health care costs among those considered to be super-users. Aurora Health Care may benefit from this new and innovative approach to care.

Purpose: The purpose of this pilot project was to create a more formalized plan for managing the most complex patients at Aurora St. Luke’s Family Practice Center (Milwaukee, WI).

Methods: During 2017, 20 medically at-risk patients ≥ 18 years of age were identified and tracked. Each patient was asked to voluntarily participate and verbally consented. Brief patient/family and caregiver surveys were conducted pre- and post-home visit. Following identification of our cohort, an interdisciplinary team meeting was conducted quarterly to discuss patients and to initiate and update care plans. The diverse medical team included a faculty physician, resident(s), clinic social worker, nurse practitioner, clinical pharmacist, registered nurse, and any other available learners. Through these meetings, we attempted to analyze and address each patient’s social situation and barriers. There was at least one home visit conducted for each patient and, overall, more frequent contact with the patients and caregivers. Additionally, pre- and postproject hospital admissions, clinic access, and emergency department (ED) utilization was tracked.

Results: Overall, the patient population had a mean age of 62.4 years and was predominately female (70%). The average Charlson score for patients was 6.2 (median: 6). (A score of 6 equates to a 10-year mortality risk of 98%.) Analysis of characteristics of the 20 patients revealed 80% prevalence of mental illness and communication problems; 70% were overmedicated. Comparing the 6-month periods before and after initiating the pilot, total ED visits decreased 20.0% (95 vs 76) and total admissions decreased 35.5% (31 vs 20). Surveys determined that patients, clinic staff, and physicians were very satisfied with the intervention. Overall, 94% of provider respondents felt more patients would benefit from being involved.

Conclusion: This well-received collaborative pilot substantially reduced hospital utilization in high-risk clinic patients. We believe this concept has large potential to provide further future benefit and may be replicated elsewhere in the system. In 2018, our pilot efforts will be extended to two residency sites for further evaluation.



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