NFMMC ER Emerging Hot Spotters Program: ‘Wrapping in Compassionate, Comprehensive Care’


Millennium Collaborative Care has been proud to extend Delivery Service Incentive Payment Program support, including Innovation Fund support, to innovative initiatives under the leadership of Sheila Kee, Executive Vice President and Chief Operating Officer, that are currently addressing social determinants of health and improving the delivery of healthcare for patients at Niagara Falls Memorial Medical Center in Niagara Falls, NY.

Sincerest thanks to NFMMC team members for sharing insights into their daily efforts to provide compassionate, comprehensive care, and truly make a major difference in their patients’ lives. 

Jenna Genova has been with NFMMC for three years. She is a graduate of Niagara University and received a Masters in Social Work from the University at Buffalo.

NFMMC ER Emerging Hot Spotters Program

By Jenna Genova, SW, Emergency Department Social Work

Throughout my time in the role of an Emergency Department social worker with the population of “Emerging Hot-Spotters” I’ve had an opportunity to meet people of all different socio economic status, and with all different reasons to present to the ED. An “Emerging Hot-Spotter” can be described as a high utilizer in the Emergency Department with three to nine visits in a four month period. Though these people originally present seeking help from the interdisciplinary staff, they ultimately require the touch and discharge plan from a social worker to ensure both safety and empathy for their present social issue that exacerbates a chronic medical condition.

When we think of having to come to the ER, one would imagine someone experiencing an emergent crisis requiring prompt medical attention. For some, coming to the ER may be their first opportunity for positive social interaction, a free meal and safety. I can specifically recall a time meeting with a patient who presented to ED for “general malaise”. This patient had a primary care doctor that he had been neglecting seeing, he was asking for a free sandwich and after receiving an alert for his multiple visits to ED, I was given the opportunity to intervene, educate and link him to local resources.

After talking with this patient extensively, at first he was apprehensive to share the root cause of the visit and discussed some of his medical diagnoses instead and his health challenges at present. While providing empathy and building rapport with this patient about his medical history he started to divulge about his son’s recent overdose leading to son being intubated and this patient, being his health-care proxy, was responsible to make the decision to extubate him and have him pass peacefully as there were weeks of no improvement. This patient became tearful in the ER and discussed having no one to talk to, to guide him through this situation and provide him with education, resources and support, and therefore has not been physically caring for himself properly. I was able to link this patient to outpatient mental health counseling, arrange for a sooner follow up primary care appointment and give him my card to call me should he need support (and he has on multiple occasions seeking encouragement and a lending ear). What is important to note is that although people present to ED requesting medical treatment, often the root of their visit stems from their need for a social worker to reduce the likelihood of a return for social barriers by wrapping them in as many services as possible to help their everyday living in their community.


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