Hospital emergency room care is expensive, and evidence shows that a small number of frequent patients are responsible for a disproportionate share of the costs. California health care providers have created programs to keep the most frequent visitors out of emergency rooms unless they are in a truly life-threatening situation.
Wendy Martinez and Sylvia Reyna work with some of these high-need patients to coach them back to health and toward self-sufficiency. The women are outreach specialists in a program called "The Bridge" at Kaweah Delta Hospital in Visalia, and have been working closely with a patient called "Julio" (to protect his identity).
"A lot of the people that we work with have no hope. They have no faith and they don't have anyone that believes in them."
Wendy Martinez, an outreach specialist
in The Bridge program
Patients have an advocate
Julio is in his late-40s, but he looks like an old man. He came to the hospital today with pain and has an antibiotic-resistant blood infection, but Martinez and Reyna have been helping with another problem. His liver is failing and he's waiting for a transplant. Julio's use of painkillers may put him at risk of being rejected for a new liver, so Martinez gives him a reality check:
"If you abuse your medication, you run out of your medication ahead of time, you go into the doctor and you want more medication ahead of time, what does that behavior sound like?" she asked. Julio insists he was sick and tells Martinez he would rather be at home, not at the hospital.
"Whose side am I on? I'm on your side," Martinez tells Julio. "I'm only telling you this because I want this transplant to happen for you. That's the way I am. I kept it real. Right? Have I not kept it real with you the whole way through?"
Last year the Kaweah Delta Hospital saw about 1,600 patients who checked into the emergency room at least five times. That qualifies them to get life coaching from Martinez and others at The Bridge. "I feel like I'm at my best when I'm helping others. You know, I just feel like I'm the vessel that God works through to help others. That's why I keep doing it," Martinez said.
Breaking the cycle
She doesn't do it alone, as the workers are typically teamed with other specialists to help these high-needs clients. Many of them are homeless, drug users, have a mental illness or a chronic disease. These are the patients other hospital workers say they can't help anymore. It's not unusual for Martinez and her co-workers meet with clients in homeless shelters, on the street or in their homes.
"We're preventing them from getting stuck in that same cycle of ending up in the hospital with no education, no resources. In the process that we're advocating with them, we teach them to advocate for themselves," she said. Some of her clients have survived a surprising range of difficult conditions, including "Doreen," a woman in her late 40s who overdosed on methamphetamines and then had a stroke.
"She'll probably be restrained because of her brain injury," Martinez said. "At times it looks like she's connecting, and then she'll fade out." Doreen is now severely disabled and her speech is a mumble. She is unable to feed herself and is incontinent and needs round-the-clock care.
Doreen lies on a bed, emaciated. Her wrists and ankles are bound to prevent her from wandering off. She's been in and out of the hospital repeatedly for months. She was wearing a soiled diaper when dropped off by a friend.
"Was she feeding you?" Martinez asks Doreen. "And changing you? She got you clean?"
Doreen mumbles a reply.
"You know that's my job. I want to make sure that you're okay, and we're going to try to find a place for you to go next. Okay? A place where you can live," Martinez said. The caregiver is trying to help Doreen qualify for Medi-Cal so she can move into a nursing home with fulltime care. That will take months.
For now, Doreen is staying in the hospital while Martinez gets through tough days like this with patience and a little bit of humor.
Compassion is a must
"Did you have a good lunch?"
Doreen's mumbled reply draws a laugh from Martinez. "I got that part. That's what they say about hospital food, huh?"
Martinez spends a lot of time in her car, driving around Tulare County to see her many clients. She's learned to deal with the repeated suffering and emotion she sees day after day. "Well, I don't turn to drugs and alcohol," Martinez said. "I have to have faith that things are going to work out as they're meant to be. As long as I know I give my best, and put my effort to the best of my ability, I am able to go home and sleep at night."
Wendy said that a college degree isn't required for her job, but compassion is. "You have to be patient. You have to be understanding. I think you have to believe that there is good in everyone. You know, you just have to find that good."
Good health and quality of life are not easy for Martinez' clients to grasp. "A lot of the people we work with have no hope. They have no faith and they don't have anyone that believes in them," Martinez said. "When you can discover that little bit in a person, I think it gives them the hope."
Poverty leads to health issues
Martinez got a phone message from the mother of a 42-year-old diabetic man - "Eduardo" -- who stopped eating in a bout of depression. The woman called Martinez in desperation. "This man basically wants to die," Martinez said. "He's killing himself. He is not compliant with his medications. He will not be compliant with doctor visits. He's a mess."
Eduardo has uncontrolled diabetes and has refused care repeatedly. Martinez referred him to a diabetes outreach specialist at the hospital, and isn't sure she can do more for him. When Martinez and another outreach worker visited Eduardo at his home, they find him in bed, under a blanket, where he's been laying for days. His heart is racing and his speech slurred.
Eduardo's mother said his last meal was a can of spaghetti and meatballs four days earlier. A check of his blood sugar level shows sky-high levels and he's close to going into a diabetic coma. He is cold, cranky and confused, but does agree to be taken to the hospital. Martinez tells Eduardo's mother to call 9-1-1 for an ambulance.
Health issues affect the family
Martinez and her co-worker give Eduardo a pep talk as they wait for the ambulance to arrive. He tells them he'd like to take a sleeping pill, but they remind Eduardo that the plan is for him to start to get better. His mother is in tears and paces in and out of the room.
"I'm too old," Eduardo's mother tells him. "I'm your mother...I need you to be okay to help me out. I can't do this by myself. I need your help. For me and for you, and for your kids...Every night [I] rub your head, you[r] feet, see how you're suffering. If you love me, do this for us."
The ambulance drivers recognize Eduardo and talk to him like they know him well. Eduardo jokes around with them, saying that he hadn't taken his insulin and that he partied the night before. The help a stumbling Eduardo as assist him to the ambulance. The Bridge workers focus on consoling Eduardo's mother as the ambulance pulls away.
"I know that you're hurting," said the diabetes outreach worker, Lydia Navarro.
"You gotta take care of you, too. Okay? For him," Martinez told her.
Investing in care cuts ER visits
A large part of Wendy Martinez' job at The Bridge is connecting clients to services like public health insurance and social security income.
The California Department of Health Care Services said increasing enrollment in programs like Medi-Cal could result in higher Medi-Cal costs.
But John Tyndal, manager of The Bridge at Kaweah Delta points out the long-term savings from the program.
"With our program if you look at the reduction in costs over the years, we're actually saving taxpayers' money," said Tyndal.
Numerous studies show the cost effectiveness of intense case management for frequent ER users. One study shows a 50 percent reduction in emergency room visits among Bridge clients a year after they entered the program. That's good for the hospital's bottom line, and it brings down the ER costs to Medi-Cal, too.
But Tyndal said the cost savings are good, but the quality of care is another important factor. "We've worked with many individuals that we've connected them to various resources throughout the community, and it's really been a turning point in their life. We have a couple of patients who, when we started working with them, hadn't graduated high school. But we got them connected to drug rehab and got them connected to a primary care provider."
Martinez' clients are improving. Eduardo, while still bedridden, is eating again and getting dental care. Doreen is heading to a nursing facility for brain trauma patients and Julio continues to wait for his liver transplant. Their stories may not have happy endings, but Martinez is helping them stay out of the emergency room.
- Community Outreach Programs at Kaweah Delta Hospital, Visalia, CA
- Characteristics of Frequent Emergency Room Users, Kaiser Family Foundation Report
- Health Care 911 - A Multimedia Investigation from UT San Diego, Center for HealthCare Reporting
- Sutter 'navigators' steer routine patients out of emergency rooms
- Frequent Users of Health Services Initiative (From the California HealthCare Foundation)