About Us

Care Management Model

The Hotspotting program maintains multiple potential tracks of care coordination to include substance abuse treatment, hospital-based, community health, and criminal justice, the latter of which will engage individuals with justice involved histories and/or critical social service needs.


The program provides each partner with two fully funded staff members: one dedicated clinician and one Certified Peer Recovery Advocate (CRPA) who will lead their focused intervention, engagement and care coordination around those most at risk and potentially hardest to reach. These fully funded and dedicated teams with each treatment partner will focus on preventing opioid harm, engaging individuals in recovery, delivering value to the health system, and addressing critical social determinants of health which impact health outcomes and lead to stressors that contribute to the initiation of a substance use disorder or relapse.


The Hotspotting program is specifically designed to help high-risk individuals receive peer-led, person-centered services ‘where they are’ in a safe and collaborative manner. Those suffering from substance use disorders are often inadequately engaged in care, have left treatment programs or have been impacted by system wide issues such as a lack of access to in-person services, which has been exacerbated by the COVID-19 pandemic.


Each of the program partners will subsequently employ their own signature intervention and care management models and techniques under this broader program, all based on the at-risk individual’s prior history, the social determinants underpinning their condition and their relationship with other agency partners. These partners are comprehensively monitored care throughout the program’s duration, ensuring fidelity to the care management model and a continued results-oriented focus on those most at-risk.

Program operations

The Hotspotting program follows a rigorous operations protocol so as to ensure that every treatment partner adheres to a common system of patient outreach, engagement and outcome reporting. This standardized system improves patient outcomes and also enables an advanced reimbursement system to be maintained which focuses on comprehensive patient engagement with cross-cutting services and patient outcome/ healthcare utilization metrics.