From Durham to Singapore: Sharing strategies that improve patient health

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Last October, results from a Schweitzer Fellowship project launched in Durham, North Carolina to improve the health outcomes of patients with complicated, chronic medical needs were shared with a global audience. North Carolina Schweitzer Fellow and Duke School of Medicine student Aarti Thakkar presented on lessons learned from the initiative at Duke Medical School’s annual Consortium of Longitudinal Integrated Clerkships Conference. The experience, she says, was “thrilling and humbling.”

Even more exciting? Watching the reaction of conference attendees, who became excited to start similar projects at their own schools that could potentially reduce unnecessary visits to the emergency department, and increase patient adherence to prescribed medication regimens.

“It was so rewarding to watch other schools become interested in getting involved and starting their own programs and to realize that the reach of [our program] can go beyond Duke and be shared across the world,” says Thakkar, who can be seen on video talking about her project here.

The program in question is the Duke Hotspotting Initiative (DHSI), in which teams of medical students provide community-based care to medically complex patients from diverse socioeconomic backgrounds. It was founded in 2015 by then-Schweitzer Fellows Morgan Hardy and Jerry Lee. Thakkar volunteered that first year as one of the medical students providing community-based care. She describes her initial involvement in DHSI as a profound learning experience that allowed her to connect the basic science she was learning in the classroom with actual patient experience.

“Over the course of the year, from visiting the patient at his home in North Durham, to attending clinic appointments to weekly check-ins, I was able to truly see the patient experience from the viewpoint of someone who not only had uncontrolled chronic disease but also socioeconomic barriers that prevented him from seeking care,” Thakkar recalls, adding that she has applied much of what she learned from the experience in her clinical rotations.

The relationship-based partnership at the heart of DHSI ensures that patients follow through on goal setting and attending primary, specialty, and mental health care appointments. The close provider-patient relationship also helps providers support patients’ attempts to improve their health in more meaningful ways.

“These patients don’t always need more medical care, but rather someone who can understand where they’re coming from in general and address the barriers that can’t be overcome in a 15-minute clinic appointment,” says Thakkar. “Our first-year medical students are the bridge between the health system and home.”

Indeed, patients say they’re benefiting from the attention DHSI gives them. In written feedback, one said that they now “trust the health care system” because their medical student “really listened” and “took me seriously.” Another saw his care radically transformed as a result of intervention by medical students volunteering with DHSI.

In that case, the patient had been to the emergency department eight times in just six months for treatment of gout and back pain—conditions that, if properly managed, should not require emergency care. After enrolling in DHSI, his student team realized that the man’s care was so disjointed and his medical appointments so numerous that he wasn’t receiving his medications on time, which caused the recurrent gout and back pain flare-ups. The team worked with him to consolidate his medical appointments and prescriptions, after which the man was able to much better control his chronic conditions and focus on what was truly important to him: undergoing cataract surgery. Just six months after working with his team of students, the man had received cataract surgery. Meanwhile, his visits to the emergency department dropped to zero.

While the benefits to patients with complex medical needs is obvious, the medical students who volunteer gain valuable lessons. First and foremost is an understanding, early in their medical career, of how difficult it can be to improve someone’s health, coupled with the value of savoring small victories. One student, for example, told Thakkar she thought she’d make an immediate difference in her patient’s life to help him change for the better. It didn’t quite work out that way, the student said. But she had experienced “incredibly rewarding” moments nonetheless, such as seeing the patient’s excitement when she and the rest of the patient’s medical team showed their investment in his health by visiting him in the hospital.

“I still believe that I am able to have a positive impact on patients regardless of how different we may be, and whether or not my impact appears immediate, and I hope to keep building on this and carry it into the wards throughout my career,” the student told Thakkar. “I am thankful that there is a program that shows us that there really is a different world outside of the walls of Duke, and I hope Hotspotting continues to teach students to appreciate not only the privileges we have, but also the impact we can have on the Durham community.”

As she continues her work with DHSI, Thakkar she is expanding its reach from Duke Outpatient Clinic, her current community site, to patients at Lincoln Community Health Center. She is also moving it in an interdisciplinary direction by partnering with nursing and social work students.

Thakkar is quick to acknowledge the role her mentors have played in her success. Drs. Goodman, Clay, Brown and Eisenson, as well as RN, BSN, Marigny Bratcher have been incredibly supportive throughout the project and instrumental in ensuring the program meets the needs of both the patients and the student volunteers.

“Being a Schweitzer Fellow has allowed me to build a strong network of students and mentors who are incredibly supportive, creative, and have been instrumental in helping me find the resources to foster and develop our project,” Thakkar says. “A project isn’t sustainable if it falls apart because one person leaves. My time as a Schweitzer Fellow has taught me how crucial it is to foster the same fuel and passion in my co-leaders and empower them to also make the project sustainable over time.”