Notes From The Hotspotters: Trouble At Home

Originally posted December 2, 2014

By Rebecca Bausinger

Heading into Section 8 housing – also known as “the projects” – our hotspotting team was not sure what to expect. Our task ahead was daunting — we had yet to enroll any of our four required patients. This would be my first home health experience. For a health care provider, going into a patient’s home can be nerve-wracking if you are not used to it. I was glad to have two of my teammates by my side. 

As part of the Hotspotting Learning Collaborative, we want to learn about the medical and social barriers that patients face that may prevent them from accessing routine preventive care and cause them to be admitted to the hospital more often than most people. We used data from the local hospital to identify “high-utilizing” patients who have been admitted at least twice in the past six months. Then we contacted the patients to offer our help. We will try to transition them away from hospital visits and toward primary care providers.

Cautiously, we knocked on the first patient’s door, not sure who would answer. The patient’s teenage son (I’ll call the patient “M”) welcomed us inside, “She’s in the back laying down.” I scanned the area as we walked through. A TV dinner lay in the trash. Aside from a few stray objects on the floor, the place was moderately clean. Once we got to M’s bedroom, my eyes adjusted to the dim lighting. Only a small table lamp was lit. The blinds were tightly shut. Her king-size bed filled up most of the room. She hesitantly began speaking to us by saying she had forgotten we were coming. Many thoughts ran through my head: Does she even want us here? Is it a mistake to pick this patient? I spotted bullets lined up on the dresser.

We asked the appropriate survey questions to determine whether M would be eligible for our assistance. As it turns out, she could use help in all areas of her life. Only in her early 30s, she had a number of chronic medical conditions, several of which caused her chronic pain, and she suffered from depression.

With no car and unable to walk to the bus stop, M struggles to make it to appointments.  And she doesn’t have a cell phone. To further complicate matters, her recent hospitalizations put her behind on electric and gas bills. If she doesn’t find a way to pay her gas bill soon – a requirement of staying in government housing – she risks eviction and possibly homelessness.

We took M on as our first patient and tried to address several of her underlying barriers to access. We promote independence, so although we couldn’t offer her a ride to her doctor’s appointments, we helped her find ways to get to them, such as setting her up for a medical assistance transportation program. Social security disability makes her eligible for a government-issued cell phone, so we gave her the appropriate forms for that. We also attempted to find church ministries and charities to pay M’s outstanding gas and electric bills.

The next time I saw M in her home, she was asleep. Her son told us that she might need to go to the ER. She had been more sluggish than usual and not acting like herself, he said. We could only encourage M to open up and say a couple of sentences. Her son decided to call for an ambulance. After M was admitted to the hospital, we learned she had had a mini-stroke and had lost our phone number, so she couldn’t ask for help. She did not suffer permanent damage, but the mini-stroke is testament to her poor arterial circulation and her volatile health condition.

When she is discharged from the hospital and feeling better, our team will return to her home to continue the work we started to help prevent future hospitalizations.

But M is just one among many patients in our health care system whose barriers to good health extend far beyond her individual diagnoses. Bullets on her dresser point to the possibility of an unsafe living environment. The dangers of that environment may be far more pressing health concerns for M than the risks of her medical conditions. Money for heat, electricity and food for herself and her son is also likely to be a more pressing day-to-day concern than management of a chronic condition. Her lack of transportation to medical appointments precludes any questions about whether medical treatments are effective. And lack of a phone precludes any concern about whether health care providers are doing all they can to make sure M doesn’t slip through the cracks. There are other patients like M on our hotspotting team and still others on the hotspotting teams around the country. And there a lot more who are not eligible for programs like this, but still need help navigating the health care system. Without cars, cell phones or home visits, they are practically invisible. It’s my hope that this project might shine a little light on them. 

Bausinger RebeccaRebecca Bausinger is a senior at Pennsylvania State University. She aspires to enter critical care and emergency nursing. She is a member of the Student Nurse’s Association of Pennsylvania and Sigma Theta Tau, the honor society of nursing.

One thought on “Notes From The Hotspotters: Trouble At Home

  1. Independence is great but you need to match it to the skill set of the person and the situation. We don’t for example ask patients to leap from a gurney to the bed we provide hands on assistance.

    How hard would it have been to simply assume that a call phone would be key to staying in touch with some of your transportation challenged patients and get them funded aprori for a month as they apply?

    If in fact SDoH are the same as an RX finding ways to deliver it to the patient where they are (deliver the drug via the mail) vs telling them to do the work. This isn’t about becoming dependent it is about providing care at the point of service.

    Then you could provide a phone with your number pre-programmed into it

    p.s would be great if you had a field for our twitter handles in the form @cascadia

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