Camden Coalition Remains Committed to 'Hotspotting' Despite Setback

A recent New England Journal of Medicine study is "not an indictment against all care management and care coordination programs," Camden Coalition's CEO says.

Despite the recent publication of a research article that generated disappointing results about its care management program for "superutilizer" patients, the Camden Coalition of Healthcare Providers is continuing its commitment to serve a complex patient population.

The Camden Coalition's "hotspotting" program targets complex patients with comorbidities and social needs. These kinds of superutilizer patients account for a disproportionate share of healthcare spending in the United States, with earlier research finding that 5% of the country's population accounts for 50% of annual healthcare expenditures. Programs such as the Camden Coalition's care management initiative are designed to help reduce these healthcare costs.

The recent research, which was published in the New England Journal of Medicine, assessed the hospital readmissions impact of the Camden Coalition's hotspotting program from 2014 to 2017.

The randomized, controlled trial featured 800 patients split evenly between participants in the Camden Coalition's care management intervention and a control group receiving usual care. The study found that the 180-day readmission rate for the intervention group was 62.3% compared to a 61.7% rate for the control group.

The Camden Coalition's care management intervention focuses on the 90-day period after hospital discharge. The program is staffed by a multidisciplinary team that includes community health workers, health coaches, registered nurses, and social workers. The team conducts several interventions such as connecting patients with social services, medication management, self-care coaching, and coordinating follow-up care.

Camden Coalition of Healthcare Providers CEO Kathleen Noonan, JD, recently spoke with HealthLeaders about the Camden, New Jersey–based organization's perspectives on the NEJM study. The following is a lightly edited transcript of that conversation.

HealthLeaders: What is your reaction to the NEJM study's finding that your hotspotting program had no effect on hospital readmissions?

Noonan: It's clear to us that there is still a lot to learn in this area. We don't think that there is a clear-cut solution for how to reduce utilization and costs for this very complex population. And because our healthcare and social service systems are siloed—and accessing services from either is complicated and difficult—we found that accessing the services that our population needed was difficult even with a skilled team.

We were dealing with issues of poverty, racism, and disinvestment that were front-and-center for our patients. Sometimes, these issues were even more front-and-center than the health issue that brought them into the hospital. So, the healthcare intervention that was trying to connect patients to social services within a 90-day time period was not sufficient.

You have to remember that this study was done between 2014 and 2017. If you did an Internet search of the phrase social determinants of health during that period, you would see it far less often than you would see it in the past couple of years. The changes that have occurred since 2017 have built up the ecosystem that is trying to connect health and social services.

HL: What lessons have you learned from the NEJM study?

Noonan: Our main lessons are that extreme hospital and emergency room over-utilization is driven by the patient's complexity and the inability of any one system to manage that complexity. What we are doing now is working with others across the country who are also trying to build new care models that can respond to the needs of complex patients.

We also are trying to figure out how to catch patients earlier. There is a lot of terrific work being done in predictive modeling and how to find complex patients earlier.

While we didn't reduce readmissions in the study, we did see an increase in SNAP participation in the intervention group, which is a promising outcome since food insecurity is a key social determinant—something we see in Camden over and over again. Many of our local hospital partners are responding to this need, with the development of food pantries, food prescriptions that are connecting patients to nutritionists, and other supports.

HL: Is Camden Coalition going to re-evaluate its hotspotting program?

Noonan: Before, during, and after the study, we have been learning about the patients and adjusting the hotspotting model. The authors of the study recognized that they knew that the Camden Coalition was going to modify certain parts of the intervention, so the examination of the intervention looked at the average effect of the program.

One thing we did two years into the study was to create a housing program called Housing First. We knew that it is difficult for us to help a patient when there is homelessness or severe housing instability. That's one change we made.

Another change we made that we were not able to get off the ground during the study period was the creation of a medical-legal partnership. For many of our patients, we found they faced difficulties because of civil cases or barriers to benefits that we needed legal help to resolve. We are now partnered with Rutgers Law School, and we have two lawyers who work with the care team. This has helped us to quickly deal with legal issues that our care team did not have the expertise to address. 

We have also worked locally to support the development of medication-assisted treatment. We've worked at the state level with partners to waive prior authorization for medication-assisted treatment.

We are trying to look at the whole system around these patients and to work at the levels of care intervention, healthcare providers, and policy to make changes that can respond to some of the barriers identified during the study.

HL: How much more work do you have to do to perfect a care management model for complex patients?

Noonan: Now that the study's data has been published, we are continuing to analyze the data in partnership with the Abdul Latif Jameel Poverty Action Lab at MIT and Rutgers University, so we can understand more about sub-populations and promising trends. We are going to use that analysis to guide us through the demographics—and the health and social history—of this population to target patients better.

There was a broad population that was included in the study, from 18 to 80 years old. So, we are trying to understand different trends for different parts of the population.

HL: What advice can you offer to other healthcare providers that have launched hotspotting programs?

Noonan: The study's results make a significant contribution to the field. But it is important to consider what the results do not say. The results are not an indictment against all care management and care coordination programs.

Other studies have shown positive results, but the populations for those studies were older and predominantly Medicare populations. The NEJM study noted that our patients had much higher levels of complexity at baseline. We don't want other healthcare providers to think that the core elements of care management have been proven ineffective. That's not the case.