Hotspotters gone cold – what happens when you change health care into something else
Hotspotters. Not everyone is familiar with this term, but it has become a mantra in healthcare since Atul Gawande popularized that term in 2011. An ambitious program in Camden New Jersey began to both identify and fix the social determinants of health, and in doing so reduce hospitalizations. This well-conceived program brought to bear all the resources that could be mustered to help people get the housing they needed, the food they needed, the health care access they needed, and virtually anything else that was amenable to positive intervention. The idea has been very simple and eminently logical, spend 1 or 2 dollars on food or transportation, and save $10 in unnecessary or avoidable healthcare expenses. Get an actual positive ROI – return on investment. By making our providers do double duty as social workers in on top of their day jobs we could get both personal and organizational successes.
The entire nation has been taken with this concept because of its compelling logic and intrinsic worth – reaching out to help our fellow man. We see the implications of this thinking every day as we ask about the social determinants of health for every visit for every person seen in an ambulatory encounter. The Hotspotter program was one of the nascent ideas that led to this widespread adoption of asking each patient about potential life difficulties they may be having. On an inpatient basis resources of social workers and case managers are devoted to addressing the needs of our patients beyond their immunizations, medications, and surgical interventions. Just the resources committed to these investigations and assessments are profound.
Now, the first results are in. In a landmark article in the New England Journal of Medicine, the Hotspotters essentially concluded that the model does not show the measurable outcomes that were expected. Although individuals benefited from the housing and the food and the transportation and the access, there was no decrease in hospitalization rates in the intervention group compared to the control group. Lots of resources invested, but the return on investment in terms of healthcare savings was just not there.
Don’t expect the questions to go away now that the benefits of such pursuits are in question, however. Once a process or requirement becomes embedded in healthcare, it stays. We will likely be asking people questions about the social determinants of health for a long time, even though it may be that our efforts are fruitless. If not totally without merit, there isn’t a benefit that we can measure.
One can wonder if this was ever really our lane. We are doctors, nurses, NPP’s, hospital administrators, social workers, and other trained professionals trained and poised to deliver healthcare. Were we ever the best instruments of change to correct the challenges of a broader society, even though we may be the best observers of the problems social inequality produces? All the patients ARE in our lane and we see what variations in finances, education, and reverse the tremendous societal problems that many of our patients face. Perhaps there is some insight here into what happens when you take experts in one field, and assume they can be experts in something – changing society – that is a big lift and that they’re not trained for.
The results are frustrating, the results are disappointing, but it’s time to move on. We should get back to healthcare, and we can continue to advocate for societal change and point out what is wrong – but we may not be the ones who can fix it – and still keep our focus on the primary mission we all trained for. Our plates are just too full right now to pursue that in which we cannot succeed.
