UPDATE: NFMMC ‘Hot Spotter’ Program

Niagara Falls Memorial Medical Center ‘Hot Spotter Program’
Continuing to Reduce Avoidable Emergency Department Visits

Niagara Falls Memorial Medical Center (NFMMC) plays a vital role serving approximately 40,000 Medicaid beneficiaries in Niagara County.

To better care for these clients, NFMMC , under the leadership of Sheila Kee, Executive Vice President & Chief Operating Officer, has worked closely with Millennium to optimize its services, including leveraging Innovation funding to reduce avoidable Emergency Department visits.

To date, results in this mission critical area continue to impress including:

  • 51% reduction in repeat ED visits for “Emerging Hot-Spotter” high utilizers
  • 21% reduction in “ED Hot-Spotter” high utilizer visits
  • 1392 combined face-to-face interventions for Hot-Spotters/Emerging Hot-Spotters
  • 962 ED diversions through sandwich and socialization component
  • 290 Nursing Home, Home Care, & Other Diversions
  • 101 engaged by Addict2Addict directly in ED or post-visit


How NFMMC ‘Hot Spotter Program’ Works

To better engage the most frequent users of the ED, NFMMC has continued to implement a multi-pronged “Hot Spotter Program” that is supported by Millennium’s Innovation Program.

According to Sheila Kee, NFMMC considers a patient a “Hot Spotter” after 10 ED visits and an “Emerging Hot-Spotter” after four ED visits. To continue to reduce avoidable ED visits, while at the same time engaging clients and meeting their needs, NFMMC continues to successfully employ a variety of related innovative initiatives.

A pop-up alert system enables members of NFMMC’s Hot Spotter Team to immediately respond to a client who is required to first stop and register at NFMMC’s new ED Information Desk.

This “first stop” enables the Hot Spotter Team member to immediately greet the patient and assess his/her needs.

For example, if a client presents a Social Determinant of Health issue such as food insecurity, they are directed to the NFMMC ED Sandwich Program and provided a meal and opportunity to visit with an NFMMC social worker.

If the issue can be addressed by primary care, the patient is directed to the adjacent Golisano Center For Community Health which also offers after-hours primary care.

NFMMC has also implemented ED-based screening of behavioral health patients.

The hospital has also developed close relationships with community based organizations and conducts “warm hand offs” from the ED to organizations such as Addict 2 Addict, Family 2 Family, which provides peer substance use treatment advocacy and assistance.

“The combination of great leadership, an incredible team of dedicated care givers, and terrific creative thinking continues to be a winning formula for success for Niagara Falls Memorial,” concluded Steve Nelson, Millennium Director of VBP and Performance.


Next Up For NFMMC:  New 7-Day Pledge Program

To continue to build on “Hot Spotter” program success, Niagara Falls Memorial Medical Center has launched a new “7-Day Pledge Program” to provide timely access to primary care after a hospital stay or Emergency Department visit to manage and improve the health of NFMMC patients.

The key program objectives are to remove barriers to rapid primary care follow-up including:

1) Inability to secure timely appointments.

2) Transportation issues.

3) Lack of patient knowledge about importance of primary care.

At the heart of NFMMC’s newest initiative practice is the “7-Day Pledge Imperative” which states:

“One quarter of hospital readmissions are preventable and inadequate post discharge follow-ups is a key factor in readmissions. By facilitating connections to primary care, the 7-Day Pledge program works to ensure that patients secure necessary care within 7-days after leaving the hospital.”

According to Sheila Kee, Executive Vice President & Chief Operating Officer, and Sarah Gatti, MS-HIT, LPN, PMP, Quality Assurance Project Leader, the 7-Day Pledge Program was originated in Camden, NJ in 2014 when a coalition of nine primary care centers and six hospitals in Camden formed a collaborative to improve primary care connections after hospitalization.

The 7-Day Pledge Program is evidence-based as supported by research published by the American Medical Association’s JAMA Journal in January 2019 reporting that the project reduced 30-day readmission rates for Medicaid patients by 4.8%. The Study also found that 90-day readmission rates for Medicaid patients were reduced by 10.7%. Other research indicates that rapid primary care follow-up from the ED is a critical strategy for reducing preventable ED visits.

Niagara Falls Memorial Medical Center is taking a two-pronged approach to the implementation of the NFMMC 7-Day Pledge Program including:

1) Primary Care after a Hospital Stay

2) Primary Care after an ED Visit

Under this two-pronged approach, a 7-Day Pledge Coordinator is focused on serving Medicaid inpatients including:
• Attending daily interdisciplinary team huddles.
• Visiting patients at bedside and informing them about importance of follow-up care.
• Scheduling patients’ 7-Day Pledge primary care appointments at the patient’s preferred date and time.
• Assisting patients with removing barriers, e.g. transportation, that would prevent them from attending their 7-Day Pledge appointments.
• Informing Care Manager in Primary Care about the inpatient encounter and forwarding patient’s discharge summary and 7-Day Pledge appointment (a primary care-based care plan is subsequently developed).
• Calling patients to remind them of primary care appointments.

In addition, a second NFMMC 7-Day Pledge Coordinator is focused on serving Medicaid ED Patients including:
• Visiting patient at bedside in the ED.
• Assessing client’s Social Determinant of Health screen and assists with removing barriers.
• Scheduling 7-Day Pledge appointment at the patient’s preferred date and time,
• Sending Telephone Encounter to the Primary Care Coordinator using eCW.
• Forwarding ED Discharge Summary to Primary Care Coordinator.
• Documenting all follow up appointments with provider name, date and time.
• Making reminder calls.

Overall, building bridges with Primary Care is essential to the success of NFMMC’s 7-Day Pledge program. To ensure these connections, NFFMC strives to ensure:
• All six NFMMC Primary Care Centers are on board with making 7-day appointments.
• All providers have been trained to use the 7-Day checklist that itemizes key issues to cover during the first primary care visit after a hospital stay or ED encounter (e.g. medication reconciliation, follow-up on test results, self-management).
• Care Manager in Primary Care develops care plans for all 7-Day Pledge inpatients

To date, early results of the NFMMC 7-Day Pledge program sow it’s gaining positive traction:

After one month; patients have expressed they feel special when they receive a 7-Day Pledge pin, They acknowledge this is good customer service.
Patients seem more inclined to attend follow-up primary care appointments:
-65% of inpatients attended primary care appointments within 7-days.
-60% of ED patients attended a primary care appointment within 7-days.



ECMC logo

The Erie County Medical Center Corporation (ECMCC) is the parent organization of Millennium Collaborative Care

Millennium Collaborative Care

1461 Kensington Ave
Buffalo, NY, 14215

t:  716-898-5389

© Millennium Collaborative Care.