Pursuing the Triple Aim in Hotspotters: Identification and Integrated Care

The Hotspotters Project. Pursuing the Triple Aim in Hotspotters: Identification and Integrated Care

Hotspotters are patients with complex care needs, defined by problems in multiple life domains and high acute care use. These patients often receive mismatched care, resulting in overuse of care and increased healthcare costs. Reliable data on (cost-)effective interventions for these patients are scarce. The goal of this study is to assess the cost-effectiveness of pro-active and integrated care. This approach includes: an intake consultation with Positive Health; multidisciplinary meetings with physician, mental healthcare nurse, social worker and the patient; a personalised care plan and proactive care management. We aim to include 200 patients, divided over 20 primary care practices.

Study Overview

• Status: Active, not recruiting
• Conditions: Chronic Disease; Multimorbidity; Psychosocial Problem; Complex Patient
• Intervention / Treatment: Other: Proactive, integrated and personalised care

Detailed Description

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 by applying a Triple Aim approach. This approach aims to simultaneously improve the individual experience of care, reduce the cost of care per capita and improve the health of populations by offering proactive integrated care.

Is proactive integrated care costeffective and does it result in better patients experience than usual care after 12 months for patients with problems on multiple life domains? The intervention consists of: intake consultation assessing health on multiple domains using positive health or similar tool; multidisciplinary meetings with physician, mental healthcare nurse, social worker and patient, personalised care plan and proactive care management.

This stepped wedge cluster RCT aims to include 200 patients, divided over 20 primary care practices. All practices start with an observation period (2-8months), followed by the intervention (12 months) and follow-up (2-8months). Total duration of intervention is 22 months. We define Hotspotters as patients with at least two incidents of acute care utilisation (defined as out-of-office GP consultations, acute psychiatric care, emergency department visits and unplanned admissions) during the past year, and problems on two out of three health domains (chronic somatic, mental and/or social problems) based on diagnosis (coded with the International Classification of Primary Care) or medication (ATC) coding.

Primary outcome: Incremental cost-effectiveness from a societal perspective. Information on cost will be based on patient-reported data obtained by questionnaires supplied with data from the GP medical files (Huisarts informatie system, HIS) and CBSmicrodata. To assess the effectiveness the EQ-5D-5L will be used for determining quality of life.

Secondary outcomes: Insight into patients experience of care, quality of life, proactive coping, and self-efficacy. This information will be gathered using interviews and questionnaires (SF-12, UPCC, PAM-13 and SE+IN itemlist). Process evaluation with the involved care professionals, integration level, the nature of the communication between healthcare provider and patient (HCCQ, OPTION5), and acceptability (AIM), appropriateness (IAM), feasibility (FIM) ,and perceived and experienced effectiveness of the intervention.

• Study Type: Interventional
• Enrollment (Actual): 41
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Netherlands
  • Leiden, Netherlands, 2333ZA
    • Leiden University Medical centre, department of Public Healht and Primary care (PHEG), location Health Campus The Hague

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

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

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Other
• Allocation: Randomized
• Interventional Model: Crossover Assignment
• Masking: None (Open Label)

Number of Arms

4

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Other: Control period 2 months; 2 months control period, followed by 12 months intervention, followed by 8 months observation	Other: Proactive, integrated and personalised care; During the intervention patients receive proactive, integrated and personalised care. An intake consultation using Positive Health tool, or a similar method, the needs of each patient is assessed. In a multidisciplinary meeting with the GP, mental health care practice nurse, a social worker and the patient, a personalised care plan is made. The personal is executed and a care coordinator maintains proactive contact with the patient. Clinical follow-up will be done via a second multidisciplinary meeting.
Other: Control period 4 months; 4 months control period, followed by 12 months intervention, followed by 6 months observation	Other: Proactive, integrated and personalised care; During the intervention patients receive proactive, integrated and personalised care. An intake consultation using Positive Health tool, or a similar method, the needs of each patient is assessed. In a multidisciplinary meeting with the GP, mental health care practice nurse, a social worker and the patient, a personalised care plan is made. The personal is executed and a care coordinator maintains proactive contact with the patient. Clinical follow-up will be done via a second multidisciplinary meeting.
Other: Control period 6 months; 6 months control period, followed by 12 months intervention, followed by 4 months observation	Other: Proactive, integrated and personalised care; During the intervention patients receive proactive, integrated and personalised care. An intake consultation using Positive Health tool, or a similar method, the needs of each patient is assessed. In a multidisciplinary meeting with the GP, mental health care practice nurse, a social worker and the patient, a personalised care plan is made. The personal is executed and a care coordinator maintains proactive contact with the patient. Clinical follow-up will be done via a second multidisciplinary meeting.
Other: Control period 8 months; 8 months control period, followed by 12 months intervention, followed by 2 months observation	Other: Proactive, integrated and personalised care; During the intervention patients receive proactive, integrated and personalised care. An intake consultation using Positive Health tool, or a similar method, the needs of each patient is assessed. In a multidisciplinary meeting with the GP, mental health care practice nurse, a social worker and the patient, a personalised care plan is made. The personal is executed and a care coordinator maintains proactive contact with the patient. Clinical follow-up will be done via a second multidisciplinary meeting.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Costs of care	Costs of care from a societal perspective is the summ of costs of care and loss of productivity due to illness or disease. Data on frequency and type of care utilization is gathered from the GP medical file, supplied with questions on mental health care use and need for addiction care. Productivity loss is determined via questionnaire. This data will be translated into cost using standard cost prices from the Dutch guideline for economic evaluations. Cost of care, together with Quality of life, will be used to assess cost-effectiveness from a societal perspective.	22 months
Quality adjusted life years	QALY measured by recurring EQ-5D-5L. Quality of life, together with cost of care, will be used to assess cost-effectiveness from a societal perspective.	22 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Level of shared decision making	Level of shared decision making will be based on audio recordings which will be scored by two independent observers using the validated OPTION5 questionnaire. If a participant is not comfortable with these recordings, the recordings may be skipped without further consequence for study participation.	22 months
Self-regulation: Patient activation measure (PAM-13)	Self-regulation consists of measures of proactive coping, patient activation, self-efficacy and intention. The first is the validated Patient activation Measure (PAM-13). Patient Activation Measure (PAM-13), a validated 13-item questionnaire, assesses self-reported knowledge, skills and confidence in health management on 4-point scales ranging from 1 (totally disagree) to 4 (totally agree).	22 months
Self-regulation: Utrechtse Proactive Coping Compentence scale (UPCC)	Self-regulation consists of measures of proactive coping, patient activation, self-efficacy and intention. The Utrecht Proactive Coping Competence scale (UPCC) is a validated 21-item questionnaire that measures self-rated competence on proactive coping with 4-point scales ranging from 1 (not good) to 4 (very good)	22 months
Self-regulation: self-efficacy and intention itemlist (SE+IN itemlist)	Self-regulation consists of measures of proactive coping, patient activation, self-efficacy and intention. The Self-efficacy and Intention itemlist, specifically created for this study, measures self-management, self-efficacy, the intention to perform certain self-management behaviors and the presence of certain self-management behaviors. Action self-efficacy ("I am confident in my abilities to [ …] " and maintenance self-efficacy ("I am confident in my abilities to [….] when encountering obstacles") will be assessed in the Self-efficacy and Intention(SE+IN) itemlist for 8 items using 5-point scales, ranging from 1 (totally disagree) to 5 (totally agree). This addresses four key behaviours selected for the purpose of this study (adequate selfcare, maintaining daily structure, discussing concerns with care professionals, asking for help in a timely manner). Behavioural execution and intention to perform will also be assessed for each behaviour.	22 months
Experience of care: Healthcare climate questionnaire (HCCQ)	Experience of care: using measures of patient satisfaction, autonomy-supportive care and qualitative evaluation Researchers evaluate patients experiences with the personalised, integrated and proactive care approach using questionaires (HCCQ and mNPS, administerd 6 months after intervention start) and a qualitative approach (after intervention ends). The Health Care Climate Questionnaire (HCCQ) is a questionnaire on perceived degree of autonomy. It consists of 6-items, scored using 7-point likert scales. A higher score means that patients perceive a higher degree of autonomy.	22 months
Experience of care: modified Net Promotor scale (mNPS)	Experience of care: using measures of patient satisfaction, autonomy-supportive care and qualitative evaluation Researchers evaluate patients experiences with the personalised, integrated and proactive care approach using questionaires (HCCQ and mNPS, administerd 6 months after intervention start) and a qualitative approach (after intervention ends). The modified Net Promotor Scale (mNPS) consists of 2 patient-satisfaction-related items that are each scored between 0 and 10. A higher score means a higher satisfaction with the care received.	22 months
Health-related quality of life: short-form 12 health survey	Quality of life will also be assessed using the validated SF-12(12-items), including 8 dimensions, namely: bodily, pain, vitality (energy and fatigue), general mental health (psychological distress and well-being), general health perceptions, limitations in physical activities because of health problems, limitations in social activities because of physical or emotional problems, limitations in usual role activities because of emotional problems, and limitations in usual role activities because of physical health problems. Items are scored on a 3- or 5-points likert scale. The total SF=12 score ranges from 12 to 56 and a lower score means a better outcome. This questionnaire is administered thrice: at the start and end of intervention, and two months after ending the intervention.	22 months
Process evaluation following RE-AIM framework: reach, effectiveness, adoption, implementation and maintenance	Data on recruitment and population reach will be gathered during participant inclusion. Process evaluation of the study will be done simultaneous following the RE-AIM framework, thus providing insight on practicalities for future implementation. The five steps of the RE-AIM framework are: Reach of target population: the number, proportion and representativeness of participants included in the study.; Effectiveness (or efficacy): the impact of the Hotspotters intervention is assessed in the primary outcome.; Adoption: The number, proportion and representativeness of care providers (that partook in the study) that is willing to initiate or continue the intervention outside of the study-context.; Implementation: the level of fidelity to intervention protocol per GP practice.; Maintenance: The extend in which the intervention becomes part of the routine care practice.	22 months
Experience of care: qualitative assessment	Experience of care uses measures of patient satisfaction, autonomy-supportive care and qualitative evaluation. Researchers evaluate patients experiences with the personalised, integrated and proactive care approach with both questionaires and a qualitative by means of an individual interview. After the intervention, patients are invited for an individual interview to gather insight into the experiences of patients.	22 months
Administering of Positive Health methodology	The intake consultation and the first multidisciplinary meeting will be audio recorded. The audio-record of the intake as well as the filled-out questionnaire or spiderweb from the intake will be used in the qualitative analysis of positive health methodology use. Themes, conversation techniques and the positive health topics addressed will be evaluated. Both deductive and inductive analyses will be employed to assess the use of positive health methodology, the importance of discussed life domains, patients' needs, problems and wishes, and how the personalised care plan was formed.	22 months
Acceptability of Intervention Measure (AIM)	Acceptability, appropriateness, and feasibility will be measured using the The Acceptability of Intervention Measure (AIM). This will be done before the intervention starts and right after the intervention for each group of GP's. This information will be gathered from care professionals working at one of the participating practices.	22 months
Intervention Appropriateness Measure (IAM)	Intervention Appropriateness Measure (IAM), together with Feasibility of Intervention Measure (FIM), measures implementation outcomes that are often considered "leading indicators" of implementation success. This will be done before the intervention starts and right after the intervention for each group of GP's. This information will be gathered from care professionals working at one of the participating practices.	22 months
Feasibility of Intervention Measure (FIM)	Feasibility of Intervention Measure (FIM), together with Intervention Appropriateness Measure (IAM), measures implementation outcomes that are often considered "leading indicators" of implementation success. This information will be gathered from care professionals working at one of the participating practices.	22 months

Collaborators and Investigators

• Sponsor: Leiden University Medical Center
• Investigators: Principal Investigator: Rimke Vos, dr, Leiden University medical centre, health campus The Hague; Principal Investigator: Marc Bruijnzeels, dr, Leiden University medical centre, health campus The Hague

Publications and helpful links

General Publications

• Tiemes V, Leming KA, Borgdorff H, Bruijnzeels MA, van Gestel LC, Adriaanse MA, van der Wel M, van den Akker-van Marle EM, Numans ME, Vos RC. Hotspotters Project: a study protocol for a stepped wedge cluster RCT on the cost-effectiveness of 12-month proactive, integrated and personalised care for patients with problems on multiple life domains and high acute care use. BMJ Open. 2025 Aug 10;15(8):e087940. doi: 10.1136/bmjopen-2024-087940.

Study record dates

Study Major Dates

• Study Start (Actual): August 2, 2023
• Primary Completion (Estimated): December 31, 2026
• Study Completion (Estimated): December 31, 2026

Study Registration Dates

• First Submitted: March 8, 2023
• First Submitted That Met QC Criteria: May 17, 2023
• First Posted (Actual): May 26, 2023

Study Record Updates

• Last Update Posted (Actual): February 24, 2026
• Last Update Submitted That Met QC Criteria: February 21, 2026
• Last Verified: February 1, 2026

More Information

Terms related to this study

• Keywords: integrated care; multimorbidity; proactive care; high care utilizer; complex patient; problems on multiple life domains; frequent flyer; hotspotter; high needs patient; personalised care; personalised care plan; positive health tool; psychosocial problem
• Additional Relevant MeSH Terms: Pathologic Processes; Disease Attributes; Pathological Conditions, Signs and Symptoms; Chronic Disease
• Other Study ID Numbers: HTSPT

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No