Is the “Hotspotters” Program Ineffective?
On January 9, the New England Journal of Medicine published an article with the results of a large randomized controlled trial of a program implemented by the Camden Coalition to serve patients with complex physical and behavioral health needs, the “super utilizers” of the system. The program is designed to engage patients using multi-disciplinary outreach teams of nurses, social workers, community health workers and health coaches (a dream team of resources in many people’s minds.). The team members accompany patients to primary care and specialty medical appointments and try to link them to existing services in the community. The rigorous study found that the program was not more effective than “usual care” for the same population. The authors concluded that “It is possible that approaches to care management that are designed to connect patients with existing resources are insufficient for these complex cases.” (p.158)
Compare this finding to the program assessment of The Health Resilience Program done by CareOregon (Oregon’s Medicaid). The program serves essentially the same population as the Camden Coalition program, though in its design, it focuses much more on the likely trauma histories of its patients that does the Camden program as described in the NEJM article. Its results seem better. (To say they are better would take several pages and would require a lot of comparing of methodologies and outcome measures.) If you choose to look up both, notice that the Camden program focuses on the disciplines of its teams and on adding existing services. The Oregon program focuses on specialized expertise of their Health Resiliency Specialists who are embedded in the 16 primary care sites of the program. The emphasis is on training to fit the exact job and the population. This is very different from the common assumption that the necessary expertise will be available if there are multiple disciplines on the team. The second important difference is that the Camden program focuses on adding services, while the Oregon program focuses on building partnerships with patients. Its use of trauma-informed care requires an more humble, listening rather than teaching approach to building these partnerships. I suspect there is an important finding in the comparison for anyone who wants to work with this group of patients. (See my chapter, Getting from “Delivering Care to Patients” to “Partnership with Patients,”).