Every month Bob sought treatment at Highland Hospital's (Oakland, California) emergency department (ED) for cellulitis. Bob was homeless, so he was unable to shower or perform necessary hygiene. Years before, Bob experienced a difficult divorce and his life fell apart. He began abusing drugs and was arrested for shoplifting and drug possession more times than he can remember. He spent much of his days in DeLauer's bookstore in Downtown Oakland, smoking, reading, and trying to deal with deep depression.

On one ED visit, staff notified Maria Culcasi, a case manager for Project RESPECT, that Bob was a “frequent user.” Culcasi met Bob and connected him to a community clinic for medical, mental health, and dental care. She helped him find permanent supportive housing (affordable housing linked to healthcare and vocational services). And Project RESPECT's benefits advocacy team helped him apply for SSI and Medi-Cal (California's Medicaid program).

Eighteen months later, Bob testified before the California Senate's Health Committee on a bill that would require Medi-Cal to pay for the type of services Project RESPECT offers. He told the committee:

Maria Culcasi helped me get treatment for drug use and depression…. Now I have a place to sleep every night and a place to keep my medicine, so I don't get sick as much. And, I have a place to keep food and prepare meals. Because of help from Project RESPECT, I don't need to go to the hospital anymore. I am also able to keep proper hygiene now so I don't have a recurrence of cellulitis. I have been clean from drugs for 18 months. I am now volunteering at the Oakland Museum and the veterans' hospital and I've reestablished relationships with my kids. It's good to be out of jails and hospitals.

Programs like Project RESPECT not only prove that offering a medical/mental health team, case management services, linkage to housing, benefits advocacy, and transportation assistance is a cost-effective way of reducing avoidable crisis care, but also that these programs change lives.

Frequent Users of Health Services

A small percentage of people disproportionately drive healthcare costs in this country. Sixty percent of Medi-Cal expenditures, for example, fund care for 5% of enrollees.1 One subset of high-cost patients is people EDs identify as frequent users, who visit EDs at least five times a year or eight times in two years to access treatment for conditions better addressed with earlier or primary care. They have complex, unmet needs and face barriers to accessing housing and medical, mental, and substance abuse treatment-barriers that contribute to frequent ED visits. Some other characteristics of frequent users:

In Alameda County, where Bob visited the county hospital monthly, 4% of patients accounted for 38% of publicly funded mental health services.3 Frequent users in California per year, on average, have:

• 8.9 ED visits
• 1.3 hospital admissions
• 5.8 inpatient days, with average charges of $45,000

The situation is similar across the country. Nine people in Central Texas made 2,678 ED visits in six years according to the Integrated Care Collaboration (ICC), the Austin American-Statesman reported in April. The visits' total cost was $3 million. Among these frequent users, three were homeless; seven had a mental health diagnosis; and eight had a drug abuse diagnosis. The ICC also found that 900 frequent users (defined as people visiting the ED six or more times in three months) made 2,123 preventable visits in 2007, representing 18% of total visits to Central Texas EDs.4

Changing the Status Quo

The experiences of people like Bob motivated The California Endowment and the California HealthCare Foundation to test approaches to address frequent users' needs. The foundations funded the Frequent Users of Health Services Initiative, administered through the Corporation for Supportive Housing, a national nonprofit that helps communities create permanent housing with services to prevent and end homelessness. Over six years beginning in 2002, the initiative financed grants to six programs in California:

• Project RESPECT (in Alameda County), lead by Brenda Goldstein, psychosocial services director at LifeLong Medical Care
• Project Improving Access to Care (Los Angeles County), lead by Jose C. Salazar, director of program development at Tarzana Treatment Centers, Inc.
• The Care Connection (Sacramento County), lead by Jana Katz, assistant dean, administration, in the School of Medicine at the University of California Davis Health System
• New Directions (Santa Clara County), lead by Malinda Mitchell, New Directions project director, and Sherry Holm, New Directions project manager, both with the Hospital Council of Northern and Central California
• Project Connect (Santa Cruz County), lead by Christine Sippl, senior health services manager for Santa Cruz County Health Services Agency, Homeless Persons' Health Project, and Project Connect
• The Bridge (Tulare County), lead by Gwendolyn Bibb, director of community outreach for the Kaweah Delta Health Care District

In 2008, the Lewin Group, a management and evaluation consulting firm, published an evaluation based on data from 598 clients who received services from initiative-funded programs for a year. Lewin found that clients reduced ED use by 30% and inpatient admissions by 14%; 241 clients enrolled for 2 years decreased their ED use by 61%, hospital admissions by 64%, and number of days spent in the hospital by 62%, which is particularly significant considering that clients who accrued extremely high hospital charges from catastrophic illness substantially impacted the data (15% accounted for nearly 85% of total inpatient charges).

What Worked

The initiative-funded programs provided services through a multidisciplinary team of case managers, physicians, mental health professionals, and sometimes benefits advocates. The teams assessed clients and provided (or linked clients to) whatever care and supports they needed.

Outreach and engagement form trust. After suffering back, neck, and leg injuries from a car accident, Jodi became addicted to pain relievers and homeless. Without housing, income, or health insurance, Jodi began visiting the ED in Santa Cruz for skin abscesses, pain medication, and asthma. By the time she was homeless for two years, she was visiting the ED twice a month. Several times she enrolled in drug treatment programs but, without a place to live, was unable to maintain sobriety.

Linda Valdez, a case manager with Project Connect, met Jodi at a sober living environment (SLE) program where she was trying to stay clean after residential drug treatment. Jodi relapsed and had to leave the SLE. So Project Connect staff met Jodi where she lived-in her car. Like many frequent users who often have traumatic experiences with the healthcare system or have become despondent over their health or homeless status, Jodi at first refused help. But after Valdez visited again and again, Jodi agreed to participate in Project Connect's transformative mix of case management and access to housing. Jodi has remained drug-free for more than two years and has stabilized her health.

In general, initiative-funded programs engaged potential clients in multiple settings, such as shelters or SLEs. Four programs adopted an electronic flagging system that allowed ED staff to identify frequent users and inform programs of potential clients. Three placed staff in EDs to facilitate access to clients. All offered incentives (food boxes, transportation, benefits advocacy, housing vouchers) to enhance participation.

Jodi notes, “At first I was suspicious of the Project Connect people. When you are that down and out, you just don't care. But they kept coming to visit me and encouraged me to think about how my life could change. It was like in 12-Step programs when they say, ‘We'll keep loving you until you can love yourself.’” In fact, staff found that creating a trusting relationship was essential to improving a client's health.

Community-based case management makes a difference. All programs offered community-based case management, including hiring licensed clinical staff to provide intensive case management and less-intensive peer- or paraprofessional-driven interventions. Intensive care with transition to fewer services over time produced the most dramatic reductions in crisis care.

A client with The Bridge offers an example of the importance of the community-based approach. The client, who frequented the ED for dysfunctional uterine bleeding, drug abuse, and hepatitis C, had lost contact with her previous outreach specialist because she was homeless. A new outreach specialist found the client and helped her create a plan to manage her conditions. The client needed surgery for uterine bleeding but because she was uninsured, the hospital had never scheduled it. The outreach specialist assisted the client with applying for and receiving county indigent care.

Before she could schedule the surgery, the client experienced a brutal assault. Then, due to a bureaucratic mix-up, the hospital told her she was ineligible for surgery. The client began using drugs and disappeared. The outreach specialist persisted, connecting to a county contact to fix the bureaucratic glitch and arrange for surgery. The specialist had gotten to know the client well enough to find her to notify her of the surgery date.

After the client recovered from surgery, the outreach specialist referred her to an inpatient substance abuse program. Although the client left after two days, she contacted the outreach specialist months later, stating she had stopped using drugs. She had enrolled as a full-time student at a community college after deciding to become an alcohol and drug specialist. She has reengaged with the outreach specialist and continues to do well.

Program directors agree that this type of contact and follow-up breeds program success. States that have attempted to institute medical home services to high-cost Medicaid beneficiaries through a statewide contractor, on the other hand, have had low engagement among people experiencing complex psychosocial barriers to treatment.

Stable permanent housing has a significant effect. Another key component to health stability is connection to permanent housing. As Bob, Jodi, and the Bridge client recognized, a place to live translates into a sense of stability, proper hygiene, a healthy diet, medication management, and trauma prevention.

According to Lewin Group data, 45% of program clients were homeless, but more than one-third moved into permanent housing as a result of the programs.2 Clients connected to permanent housing reduced ED use by 34%, whereas clients who remained homeless or lived in shelters or transitional housing reduced ED visits by 12%. Clients who obtained permanent housing decreased their number of days in the hospital by 27%, but those not connected to permanent housing increased the number of days they spent in the hospital by 26%, resulting in a 49% increase in charges. Lewin surmised the longer hospital stays were the result of hospitals' reluctance to release recovering homeless patients to the streets. 2 Moreover, people who are homeless are more likely to experience complex medical conditions than stably housed people,5 and homeless people die at twice the rate of people who are housed.6

Medi-Cal reimburses fees for ED visits and other urgent care but restricts reimbursement for the multidisciplinary approaches these programs offered. The Corporation for Supportive Housing sponsored legislation in 2008 to create a statewide frequent user program that would require Medi-Cal reimbursement for these services. While the legislature passed the bill overwhelmingly, Gov. Arnold Schwarzenegger vetoed it. At this time, we don't have plans to reintroduce the bill, since we've been told the governor would again veto it. Instead, we are trying to find other avenues, like working with the administration, to get these services reimbursed.

Conclusion

The Frequent Users of Health Services Initiative programs are not the only ones in California or the country targeting intensive multidisciplinary services to people who frequently visit EDs for avoidable reasons. Hospitals, local communities, and a few states are beginning to recognize the benefits of directing resources toward services in the short term to reduce high-cost care over the long term. Our hope is that more states and communities will realize the costs of failing to meet the needs of these vulnerable and complex clients.

For more information, e-mail sharon.rapport@csh.org.

References

1. MaCurdy T, Chan R, Chun R, et al. Medical Expenditures: Historical Growth and Long Term Forecasts. San Francisco:Public Policy Institute of California; 2005. www.ppic.org/content/pubs/op/OP_605TMOP.pdf.
2. Linkins KW, Brya JJ, Chandler DW. Frequent Users of Health Services Initiative: Final Evaluation Report. The Lewin Group; 2008. http://documents.csh.org/documents/fui/FUHSIEvaluationReportFINAL.pdf.
3. Chandler D, Spicer G. Capitated assertive community treatment program savings: system implications. Adm Policy Ment Health 2002; 30 (1): 3-19.
4. Roser MA. Austin's ER got 2,678 visits from 9 people over 6 years. Austin American-Statesman. April 1, 2009. www.statesman.com/news/content/news/stories/local/04/01/0401er.html.
5. Kushel M. Homelessness and health care in California: the chicken and the egg. California Progress Report. July 19, 2007. www.californiaprogressreport.com/2007/07/homelessness_an.html.
6. Santora M. Health of the homeless is worse than imagined, new study finds. New York Times. January 31, 2006.

Behavioral Healthcare 2009 May;29(5):22-24