Roberta Capp, MD, MPH
By Mark Couch
(December 2015) An internship program designed by a University of Colorado emergency
medicine physician helped more than 3,500 patients address their health
needs this past summer and offers a model for improvements that could
help the nation’s healthcare system save money.
The Student Hot
Spotters were a crew of about 20 undergraduates, recent college
graduates and graduate students who worked last summer in the emergency
department of University of Colorado Hospital on the Anschutz Medical
Campus. They were available 24/7 for seven weeks in the emergency
department to help patients with follow-up care needs.
did is a health screening where they asked patients about food
insecurity, housing insecurity, insurance, their primary care
provider,” says Roberta Capp, MD, MPH, assistant professor of emergency
medicine and designer of the program.
“They looked up on the
Medicaid website to see whether patients had active Medicaid, whether
they were part of the Accountable Care Collaborative program or not and
then, depending on their answers, the health screening tool that we
developed would tell them what to do.
“If the person said they
went hungry for a number of days in a month, they would provide them
with food pantry services,” Capp says. “If they said homelessness, the
Hot Spotter would connect them with homeless resources. If they said no
primary care provider, we would find them a primary care provider and
then get them that appointment.”
The service provided by the Hot Spotters made a difference to the care that could be offered in the emergency department.
“The hard part for us is that we don’t have time to sit there and talk about
what are the issues and what are the barriers,” says Alexander Ebinger,
MD, assistant professor of emergency medicine and attending physician
in the emergency department. “Is it that you don’t have a ride, or that
you don’t know who to call to get an appointment?” The Hot Spotters were
able to address those concerns.
“They were always there saying,
‘Who can I help?’” says Ebinger. “‘Can I go see this person and talk to
them?’ So they were pretty proactive. In the event I needed one of them,
I would just ask, ‘Would you mind seeing a patient and seeing if you
can help them get a primary care appointment?’”
The Hot Spotters made getting primary care easier for the patients.
“They got so in tune with the patients and having patients go home with a
primary care doctor appointment in their hand was mind-blowing to me as
an ER nurse,” said Sandra Fogel, RN, who served as liaison between the
Student Hot Spotters and the Emergency Department.
done this for almost 15 years and you see cases where we have to tell
patients, ‘We didn’t see anything, but if your pain persists, follow up
with your primary care doctor.’
“And we know that’s not going to happen because they don’t have a primary care doctor and if they call, the appointment is going
to be one to two months away. During the time when the students were
here, patients would go home with an appointment the following week, if
not the following couple of days, and that was amazing.”
And the service
made a difference in the community.
Rich McLean, a leader with
Together Colorado and a board member of Aurora Health Access, says:
“Often when you go to the emergency room, you get some instructions and
it’s over and done. And those instructions may or may not get done.
This is revolutionary for our community because it’s not over and done.
It’s changing a lot of lives.”
The program started in summer 2014 with a smaller group of interns and an all-volunteer cast of support.
“That first year was
really great,” Capp says. “We reached out to about 650 people and they
were only here from 9 to 5 Monday through Sunday for about seven weeks.
The students went to do a home visits, I went on a home visit with the
fire department. It was super educational.”
In this year’s class,
the Hot Spotters spent a full day during the first week of the
internship on a community bus tour to understand the needs of patients
from their point of view.
“We did a whole community tour that
lasted for about 10 hours,” says Capp. “We stopped at all the different
organizations in the areas that we thought were hotspots for patients.
We went to the food pantry, we went to Arapahoe House, which is a detox
center, we went to Aurora Mental Health Center, a crisis center, the
homeless shelter, Comitis, we went to the local FQHC (federally
qualified health center) clinic in the area that takes a lot of Medicaid
patients. We went to the Asia Pacific Center, we went to community
health centers that held community activities for people. So they really
had an idea it’s located here. This is what they can do for you. It’s
The Hot Spotters also scouted for clinics who would be willing and able to take new Medicaid patients.
of their first assignments was to do a scavenger hunt of primary care
clinics that took patients with Medicaid and no insurance,” says Capp.
“And the team that got the most clinics would then get a prize. They
were supposed to take pictures in front of every single clinic that went
to and they could only find clinics in Aurora because most of our
patients come from here or Denver. It was really eye-opening.” It was
also practical because they could put those findings to good use.
put all of their information together and created an online map they
could then use to find clinics for patients,” says Capp. “When they
started they knew which clinics they could go to and they knew where the
person lived, so they could put in their address and it would pop out
what clinic and what days and how long it would take to be seen.”
For Capp, the program is a professional accomplishment that draws from personal experience.
was born and raised in Brazil and I moved to the States when I was 14
turning 15,” Capp says. “It was just my mom, my sister and I and we were
pretty poor when we moved here. We moved into an empty
one-bedroom apartment and we slept on the floor. We all three worked as
housekeepers. We started basically from scratch, so those times really
resonate with me as I’ve gone through living the real American dream.”
Capp graduated magna cum laude from the University of Colorado-Boulder in 2003 with a BS in molecular, cellular and developmental biology and earned an MD from Harvard Medical School in 2007.
I went through school I realized that there are lot of health care
access issues that those who live in poverty have to face and it’s not
just health care access,” Capp says. “If you don’t have food on the
table, that’s going to be your No. 1 priority. If you don’t have a place
to live, that’s going to be your No. 1 priority. So it’s not just a
prescription that you end up giving the person, it’s understanding where
they’re at and how can you get them to that next step. “
Still, medical training doesn’t prepare physicians to help patients facing such challenges.
what really takes time and a lot of effort and it’s outside of what you
learn in medical school,” Capp says. “And we’re never really taught how
to address those situations, what do you do. It’s all been pushed
toward the public health system when at the end of the day, health is
not just about the prescription or health care access, it’s about
As a fellow at Yale University, Capp was part of the
Robert Wood Johnson Clinical Scholars Program and there she focused on
“services research,” searching for ways to improve care delivery.
“This is revolutionary for our community because it’s not over and done. It’s changing a lot of lives.”
Student Hot Spotters toured the community to understand the needs of
patients from their point of view.
A virtue of the Student Hot Spotters program was that it offered a
model that could be deployed quickly in other locations, says Jennifer
Wiler, MD, MBA, associate professor and vice chair of emergency medicine
at the School of Medicine and adjunct associate professor at the
University of Colorado Denver Business School.
“It was an
opportunity to demonstrate that high-utilization patients could benefit
from care coordination from interprofessional teams,” says Wiler, who
helped Capp build the Emergency Department infrastructure for the
Student Hot Spotters program. “And we could quickly train people from
disparate backgrounds in an effective and cost-effective way.”
Student Hot Spotters program complemented another initiative, called
Bridges to Care, aimed at helping high-utilizing patients of the
emergency department in Aurora find primary care that would be cost
effective and more appropriate for those with longer-term, chronic
The Bridges to Care project is modeled on an effort developed by Jeffrey Brenner,
MD, in Camden, N.J. It is funded primarily by the Center for Medicare
and Medicaid Innovation to test whether the processes pioneered by
Brenner can be applied in other locations.
Some patients who rely
on emergency departments for care have needs beyond the immediate
medical issue that brings them to the emergency department. Some have
mental-health needs or substance-abuse problems. Others lack insurance
or need housing and food. And while the treatment needs can vary widely,
the payment system for emergency care doesn’t compensate staff for
assisting patients with such needs.
On a panel sponsored by the
Brookings Institution last spring, Wiler reported that the Bridges to
Care program has shown some signs of success, with 550 patients
enrolled since 2012. Six months after a Bridges to Care intervention,
about 90 percent of the patients seek primary care services, rather than
emergency department/inpatient care, for their health-care needs. This
assistance helps reduce emergency department and inpatient visits by
these patients and, according to Wiler, showed a $2 million cost savings
to the health care system.
Still, the Bridges to Care program is
aimed at a group of patients who frequently rely on emergency
departments to provide care that could be provided by a primary care
practice. The Student Hot Spotters was intended to catch all who need
support, not just those considered “high utilizers.”
are reaching out to all patients because you don’t have to wait until
they come in three times to help them,” Capp says. “You should be able
to help them the first time so you don’t have so many who are here two
or three times. So the dream program would really be to replicate this
not just with students, but with staff, 24/7 in the emergency
department, to be able to provide these services and to help save a
substantial amount of money.”