Pursuing the Triple Aim in Hotspotters: Identification and Integrated Care

Launched by LEIDEN UNIVERSITY MEDICAL CENTER · May 17, 2023

Keywords

ClinConnect Summary

People with complex problems on multiple life domains, so called 'hotspotters', receive fragmented care. This is difficult to manage by patients and care providers , leading to little effect of care and persistent unmet needs. The accumulation and complexity of problems often leads to high medical expenses. Next to their high medical spending levels, hotspotters´ experiences with the healthcare system are low as the healthcare system is not (yet) successful in dealing with their needs. Interventions aimed at the complex situation of hotspotters in our current healthcare system might benefit...

Gender

ALL

Eligibility criteria

• Inclusion Criteria:
• • The patients are ≥ 18yrs
• • The patients are registered within one of the participating GP practices.
• • Patients with at least two acute care encounters in the past 12 months. Acute care encounter is defined as an encounter with out-of-hours GP service, emergency care or acute mental health care.Patients have problems registered in the GP Information system on at least two out of three of the following domains: somatic, mental or social. Somatic problems is having at least one ICPC code on the problem list. Mental problems is having at least one ICPC code from the "P"-chapter on either the problem list, as a reason for encounter, and/or having medication prescribed related to mental health problems. Social problems is having at least one ICPC code from the "Z"-chapter or as reason for encounter, and/or having medication prescribed related to social problems.
• Exclusion Criteria:
• • The patient is terminal.
• • The patient is living in a residential home.
• • The patient has dementia or a disability that prevents them from communicating effectively.The patient already has experience with the positive health tool.
• • The patient is not competent to make decisions concerning their health. This wil be assessed by the patient's own general practitioner.
• • Veto of the GP