Members of our community know the hot-spotting concept very well. This family doc says don't stop with hot spots. Behind every hot spot, there's a cold spot that we need to address.
By Jack Westfall, M.D.
The concept of hot spots isn't new — Dr. Jeffrey Brenner's work was featured in Progress Notes
when he was named a MacArthur Genius in October. Using medical billing data from hospitals in Camden, New Jersey, Brenner identified a small group of very high-cost patients. These “super-utilizers” repeatedly accessed emergency rooms, hospitals and doctors’ offices for complex medical conditions compounded by difficult social situations and often lived within small geographic areas, a neighborhood, city block or single building. By providing and coordinating the individual medical care and social services for these medical “hot spots,”
Brenner and his group were able to reduce the cost of their care by up to half.
But behind every individual who is a hot spot, there is a cold spot where that individual lives
. In these cold spots, the social determinants of health
, community support and access to primary care and behavioral health have broken down. Identifying individual patients with high-utilization of health care is now relatively easy given the vast improvements in health information technology and electronic health records, but taking hot-spotting a step further, cold-spotting can help us address the community problems behind the people’s problems.
Cold-spotting finds communities, down to the city block, that do not provide the essential opportunities for health: safe sidewalks, good air quality, social integration, grocery stores, education, employment, behavioral health, primary care and public health. Cold spots are common in poor urban communities similar to Camden, but they can exist among the endless rows of little boxes made of ticky-tacky of our suburbs, or the gated communities of the affluent. They lack the warmth of social support. Cold spots contrast communities that have “low-utilization” – often neighborhoods with well-lit streets and smooth sidewalks, safe cul-de-sacs, green space, walking trails, integrated primary care and behavioral health, and a vibrant economy that provides individuals and families with education, employment and purpose. Communities with low utilization are packed with community organizations that engage individuals, where neighbors know each other, support each other, and social isolation is rare.
Whether hot-spotting or cold-spotting, the methods of identification are the same: find high-utilization of expensive medical care. Hot-spotting identifies individuals with high-utilization of emergency and hospital care. The hot-spot cure is to provide more intense low-cost ambulatory care and social services. Hot-spotting provides individualized services to improve individual health. It is effective at decreasing hospitalizations by replacing acute illness care with comprehensive chronic disease management, community health workers, and improved home-care and self-management. Dr. Brenner’s approach promises to help thousands of individuals in our communities and should be replicated throughout the nation.
Hot-spots can exist within cold-spot communities, but the solutions to cold-spots are very different. Using locally relevant actionable data, cold-spotting identifies problem places and provides an opportunity for engaged community building. The social determinants of bad health will not be sustainably improved without programs aimed at the community, block, town, city and hospital catchment area — the health problem shed. It is not about an individual; it is about a system, a culture and a community.
The 1967 Folsom Report
proposed a broad framework for supporting comprehensive personal health care, community health, social engagement and workforce development, all anchored within a local “community of solution.” The community of solution concept arose from the recognition that complex political and administrative structures often hinder local problem solving by creating barriers to identification of local needs and local solutions. Today’s pressing need to defragment and improve the value of health care requires a setting that fosters improvements in the social determinants of health. A strong community of solution improves the community, which in turn produces good jobs, effective education, safe housing, public health and improved access to primary care. The recent renewal of the community of solution concept may be the anchor-point for identifying and mitigating cold spots in our communities and can lead to improved individual and population health.
The recent Institute of Medicine report on integrating primary care and public health
provides additional encouragement to actively bring together the essential partners to build programs that promote population health. This combination is further strengthened by the addition of integrated behavioral health. By assembling the asset shed of integrated primary care, behavioral health and public health, we have the opportunity to build robust local, regional and statewide communities of solution. The answer is not just more money and resource, but in building a local community of solution that addresses the social determinants of health.
We know this works.
Dr. Brenner’s approach provides evidence that when you engage patients, provide them with education, training and opportunity, their health improves and they cost less. How can we take this evidence and apply it broadly, not just to individuals, but also to neighborhoods through communities of solution?
Cold-spotting requires a shift in our thinking. The health care problems and overrun costs are not due to individual patients. Our problems are systemic and community-based. The problem sheds are not in individual homes or with individual patients, the hot spots. The problem sheds are larger, wider cold spots. The cure requires a community approach, linking public health, primary care and behavioral health in explicit partnerships that address the needs of the individual and build an environment and community that supports healthy living. Together, when we build a community of solution, we eliminate cold spots, which will also eliminate hot spots.
After 20 years in academic family medicine, Jack Westfall, M.D., is C.M.O. of Colorado HealthOP, a non-profit, member-governed, health insurance cooperative. Jack practiced rural family medicine in Limon and Yuma, Colorado, for 12 years and is the founder and director of the High Plains Research Network. He is married to Dr. Audrey Yee and they have two children, Matthew and Noah.