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Healthcare Hotspotting: Camden's data-driven strategy for coordinated care

Akshita Singh

Healthcare hotspotting is a care management technique which makes strategic use of healthcare and social services data in order to better serve the small subset of high-needs, high-cost patients in a given population. The Camden Coalition in Camden, NJ successfully employs this technique to identify, engage, and assess patients in real time. The Camden team then deploys tailored, evidence-based strategies to holistically address each patient's constellation of needs, anchoring these interventions in authentic healing relationships.

A relatively small number of individuals in the United States are responsible for a disproportionately large percentage of costs incurred in the healthcare system. The system is designed to work for the average patient, and like many large systems, it struggles to help extreme patients, or “outliers”. The outlier are typically labeled super-utilizers or high-cost, high-need individuals. Behind the numbers, they are the patients that the system (as currently designed) inevitably fails; over time, their chronic conditions worsen, leading to ever more expensive, invasive, and risky treatment. 

Screen Shot 2019-06-27 at 3.57.20 PMAcross the country, a small percentage of the population incurs the majority of healthcare costs.

The term "healthcare hotspotting" was inspired by the hotspotting data strategy used in policing to identify geographic locations where high levels of crime occur. Whereas police hotspotting maps crime by location in order to focus police resources on the hot spots, healthcare hotspotting uses this methodology to focus on the outlier individuals moving through health and social systems and accessing more services. Camden Coalition's founder, Dr. Jeffrey Brenner, actually made block-by-block maps of the city, color-coded by the hospital costs of its residents, and looked for the hot spots.

Through their initial hotspotting analysis, the Camden Coalition identified the two most expensive city blocks. Both blocks were in north Camden: one had a large nursing home called Abigail House, and one had a low-income housing tower called Northgate II. Dr. Brenner found that between January of 2002 and June of 2008 approximately 900 people in the two buildings accounted for more than 4000 hospital visits and about $200 million in healthcare bills. One patient in particular had amassed a tally of 324 admissions in just five years. The most expensive patient cost insurers $3.5 million.

After Camden identifies a high-need or high-cost individual, community-based support teams – comprised of nurses, social workers, behavioral health specialists, and community health workers   engage individuals in real time, often when they are admitted to a hospital. This initial effort may begin in the hospital but then extends out into the community, where the team visits individuals in their homes, accompanies them to appointments with primary care providers and social service agencies, and aids in navigating the splintered and complicated health and social service environment that surrounds each individual.

Screen Shot 2019-06-27 at 3.57.35 PMAn example of the Camden Coalition's Hotspotting Analysis.

Hotspotting uses this data to discover the outlier individuals, understand their complex health and social needs, and then design effective interventions and dedicate resources accordingly. Increasingly, this best practice is being propelled by a movement of hotspotting communities devoted to building a new system of multi-disciplinary, coordinated care that treats the whole patient and attends to the non-medical needs that affect health: housing, mental health, substance abuse, and emotional support, to name a few.

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