Interprofessional Education Hotspotting: A Community-based Approach for Addressing Health and Health Care Utilization UNIVERSITY OF UTAH FACULTY AND STAFF ADVISORS Timothy Farrell, MD Associate Professor, Director of Interprofessional Education, School of Medicine, VA SLC Geriatric Research, Education, and Clinical Center Sara Hart, PhD, RN,  Associate Professor, Director of Student & Community Engagement College of Nursing Marilyn Luptak, PhD, MSW Associate Professor, Chair of MSW Aging Concentration College of Social Work Osman Sanyer, MD Associate Professor School of Medicine Kyle Turner, PharmD, Assistant Professor, College of Pharmacy UNIVERSITY OF UTAH STUDENT HOTSPOTTERS Sara Dunham, 4th year medical student FeliAnne Hipol, public health doctoral student Mike Newman, public health doctoral student

Objectives Describe Hotspotting as a method for intervening with patients who have highly complex needs. Consider approaches for using Values-driven Outcomes Data to identify individuals who may benefit from a Hotspotting intervention. Identify appropriate educational outcomes for Interprofessional Education (IPE) teams participating in an IPE Hotspotting Immersion. Describe the processes and challenges of creating and implementing IPE Hotspotting teams. Discuss the benefits of successful Hotspotting for patients, health professions students and health care delivery systems.

Project Goals A rigorous and sustainable IPE Hotspotting Immersion: building IPE Competencies with knowledge and skills for effective systems-based practice addressing drivers of health and healthcare utilization for vulnerable populations in our community improving health and wellness of individuals with highly complex needs reducing total costs of care for high utilizers of health care.

Background Hotspotting refers to collaborative work of interprofessional teams seeking to use local data to gain insight and intervene in the root causes of high healthcare utilization and poor health outcomes for selected patients and populations. The Housing First Model provides chronically homeless individuals with permanent supportive housing first, and voluntary, flexible, wrap-around social services, substance abuse treatment, education, and employment.

Participants Public Health, Medicine, Nursing, Social Work, and Pharmacy students Housing First Residents Focused and intensive multidisciplinary care coordination and care management with individuals who have highly complex medical and behavioral health needs Health Sciences Faculty, Social Work Faculty and Community Case Managers

Camden Coalition Interprofessional Student Hotspotting Learning Collaborative Teams receive in-depth training to: support patient wellness identify and address social and structural determinants of health improve the coordination of health care and social services. lead and participate in effective teams

Teams: Interprofessional & Multi-sectoral ACADEMIC PARTNERS COMMUNITY PARTNERS College of Nursing Undergraduate Nursing College of Social Work MSW Aging School of Medicine Undergraduate Medicine PhD Public Health College of Pharmacy PharmD College of Health Camden Coalition for Health The Housing Authority of the County of Salt Lake 4th Street Clinic Homeless Health Clinic University of Utah Health Care Enterprise Date Warehouse Community-based Clinics

Educational Outcomes & Student Value-added Teams learned to support patient wellness, identify and address social and structural determinants of health and improve the coordination of health care and social services. IPE Hotspotting Teams received in-depth training via the Camden Coalition: systems-based practice trauma-informed care social and structural correlates of health team building communication advocacy

Educational Outcomes: KSAs KNOWLEDGE Systems resources Health policy Health care financing Population health Public health systems Health care economics Social context of health Social determinants of health Roles & responsibilities SKILLS Patient and community advocacy Team-based care Coordination of care Systems change Systems interactions Community needs/resources Interprofessional communication ATTITUDES Cost-benefit consideration Social justice and equity Mutual respect and shared values Patient/population-centered care Shared accountability

Value: Data and Models Enterprise Data Warehouse participant eligibility determined by health care utilization data Measuring Total Costs of Care as an Outcome cost and claims data opportunities and challenges Testing Hotspotting as value-added education Informing new value-based models of care

CHALLENGES & OPPORTUNITIES Learning/Understanding Each Other: health care providers, social service providers, and housing providers speak different languages and are regulated by different governing bodies Participant Vulnerability: unique, dynamic and highly complex health and social needs of participants Academic Hurdles: cross-curricula coordination, student recruitment and sustaining student/faculty engagement Navigating Legal Consent and HIPAA: working across the health sciences and health system requirements while ensuring participant safety and consent.

Discussion Team Formation Using Health System Data Curricular v. extra curricular Student experiences with team forming and working with participants Using Health System Data Sources and access Participant eligibility Outcomes measures Curriculum and Content Camden Hotspotting Collaborative Localizing and making it uniquely Utah Looking Forward Hotspotting & IPE System synergies