Hotspotting in primary care: An interdisciplinary model for medically complex, socially at-risk patients

Abstract

Context: Medically complex, socially at-risk patients face numerous additional challenges when navigating the healthcare system. Hotspotting is a coordinated care model that promotes health equity through multidisciplinary teams that address the medical, social, and economic barriers faced by such patients. Several healthcare delivery models have been implemented nationally to address the multifaceted needs of the highest-cost patients, known as “superutilizers.” Traditional hotspotting programs aim to reduce healthcare spending by targeting superutilizers of the emergency department. At three clinic sites of Advocate Aurora Health in Milwaukee, hotspotting teams identify vulnerable patients in a different manner – by direct referral from patients' primary care providers. Objective: The goal of this project is to improve patient care by educating patients, providers, healthcare administrators, and communities about the hotspotting model that is unique to Advocate Aurora Health in Milwaukee. By disseminating this information through written publications, we hope that this hotspotting model will be implemented at other clinic sites. Study Design: Qualitative study.