Siena’s Interprofessional Complex Care (IPCC) Team offers students an opportunity to identify and work with individuals who are experiencing complex healthcare challenges in our local community. Teams consist of ~6 students from a variety of disciplines including nursing, social work, and those preparing for the health professions. Teams are co-led & supervised by faculty from these three disciplines. Students spend on average 35-45 hours per semester working with local organizations to identify individuals that would benefit from the support of the IPCC team. Once identified, the team works with the individual to overcome barriers to effectively managing their health. In addition to the direct experience working with individuals (patients), team members also complete a corresponding curriculum. This provides a unique opportunity for student team members to develop competencies in:
Interprofessional care
Community based skills
Communication skills
Client centered & strength based engagement
Goal setting
Advocacy
Health literacy education
History
Drs. Elisa Martin, Dan White and Jenna Thate
Since 2021, faculty from nursing, social work, and health studies have been developing an academic model to better prepare multidisciplinary teams of students to partner with individuals with complex social and health care needs. Initially derived from the Camden Coalition’s “hotspotting” model, Drs. Thate, Martin, & White have been refining a complex care curriculum that aligns with the strengths and limitations of a liberal arts institution not directly associated with a large academic medical center. Building upon Siena’s long history of community engagement, the teams partner with local human-services nonprofit organizations to address the unique health-related social needs of medically complex and socially vulnerable community members.
Our Franciscan ideals guide us to work with community members who are marginalized or treated inequitably by systems and structures in society. Student interventions target needs related to the social determinants of health such as a client's environment (housing, neighborhoods), ability to work (e.g., driver’s license), social support networks (e.g., religious affiliation, community organizations), and age cohort.
Our primary aim is to prepare a healthcare workforce that has the skills to partner with patients to overcome systemic barriers and empower them to take an active role in achieving optimal health. Students who participate on our IPCC teams become knowledgeable of systemic barriers, and develop case management skills so they are prepared to launch into health profession careers or graduate programs while also helping individuals they work with have better health outcomes.
A Little About Hotspotting
Hotspotting is a health care method aimed at reducing costs while improving patient health by identifying “super-utilizers” (those with frequent hospital visits/stays), that provides hands-on, individualized interventions for patients with complex social and health care needs. A relatively small group of healthcare “super-utilizers” drive a disproportionately large proportion of healthcare expenditures. Healthcare navigation and barrier reduction efforts have been shown to improve their health outcomes, reduce hospitalizations, and reduce healthcare spending over time.
Healthcare hotspotting has its origins in Camden, New Jersey where a local primary care physician, Jeff Brenner, noticed that a small group of “super-utilizers” were spending time in and out of hospitals and emergency rooms. This group of people seemed to be concentrated in particular neighborhoods and even in particular buildings in those neighborhoods. Brenner realized that people who were ending up in emergency rooms and requiring multiple hospital stays per year were also facing a mountain of barriers outside of the healthcare setting (Gawande, 2011). In the past two decades, a variety of programs have been developed to address these complex care needs and to improve health outcomes for this particularly vulnerable group of “super-utilizers”. One of which was the student hotspotting programs across the U.S.
IPPC Workshop August 2025
On August 7-8, 2025 the IPCC team (Martin, Thate, and White) facilitated an Interprofessional Complex Care Workshop attended by 23 professionals from eight higher education institutions (Daemen University, LaSalle University, Lehman College, Misericordia University, Messiah University, Stony Brook University, and Touro University). The workshop was supported by the generous Highmark Blue Fund grant that was awarded to our team in August 2023. The goals of the workshop were to share our model and provide time and space for teams to confidently plan and implement interprofessional teams on their own campuses.
