Dolores Salaz-Talbert, RN, PHN, a public health nurse who works for Santa Cruz County’s Project Connect program, partnered with a co-worker and began to search the city for her client. They checked the local homeless shelters, under a bridge overpass, and other common daytime hang-outs. When Salaz-Talbert finally did find her client, she had good news: She had secured temporary lodging for the client and a primary care physician to treat her chronic liver disease.
It was a typical day for Salaz-Talbert, whose job entails steering frequent users of the community’s emergency departments to primary care clinics and other community-based services. Half her clients are homeless, all are low-income, and 60% have either a substance abuse disorder, a mental health disorder, or both.
Project Connect is a community-based case management program run by the county’s Health Services Agency. The program was established more than five years ago to reduce avoidable visits to overcrowded EDs by high-risk frequent ED users.
The Frequent Users of Health Services Initiative, originally funded by the California HealthCare Foundation and The California Endowment, implemented projects in six counties: Tulare, Alameda, Los Angeles, Sacramento, Santa Clara, and Santa Cruz. Preliminary data reveal the program has helped drive a 35% decline in ED visits by participating patients, reduced ED and hospital charges by $9,715 per frequent ED user, and resulted in a 30% reduction in hospital admissions by these users.
Identifying the Necessary SupportDelores Salaz-Talbert, RN, PHN (right), of Santa Cruz County’s Project Connect program interacts with patient Larry Siegfried.
ED nursing staff at Dominican Hospital and Watsonville Community Hospital, both in Santa Cruz County, help track and identify frequent ED users and alert Project Connect staff when frequent users show up in the ED. They are identified as having co-occurring disorders and having used the ED eight times in the last year or five times in the last six months. Salaz-Talbert’s job is to initiate contact with clients, assess their needs, provide direct care and support, and build trust and relationships with them. Assisting her is a team of healthcare professionals that includes a nurse practitioner, a substance abuse case manager, clinical social workers, and social work interns.
Our strategy is to determine their pattern of ED use, identify what issues and needs are driving it and what kind of support we can provide them, says Christine Sippl, MPH, director of Project Connect. Often that begins with providing basic needs such as shelter, food, and transportation. Once these needs are met, the team can focus on advocating for income support through government programs and for health coverage through Medi-Cal, Medicare, or local programs. Finally, the team helps with psychosocial issues such as domestic violence or family problems and providing primary care for chronic health, mental health, alcohol, and substance abuse problems.
Much of the success of the program relies on the ability to find housing for these individuals, says Brenda Goldstein, MPH, director of Project Respect, the ED frequent user program in Alameda County. She says approximately 50% of frequent users in the county are homeless. Once we find them housing, it brings an incredible change in how they use the healthcare system, Goldstein says. They start using the ED less and getting more regular care because they have more stability in their lives.
Their medical care is very fragmented when they use the ER as their primary means of healthcare, agrees Denise Kirk, RN, ED case manager at Alameda County Medical Center and the designated project liaison for Project Respect. We’ve found that if we can direct these people to a primary care clinic, this translates into more preventive care and regular health maintenance and therefore, fewer visits to the ED.
Project Respect also works closely with Alta Bates Summit Medical Center to identify frequent ED users. Kirk says she checks the ED census daily to identify them. I try to meet with them before they are discharged and encourage them to follow up with a Project Respect referral, she says. One of the biggest challenges is establishing their trust so they will follow up after they leave the ED.
The nurse practitioner plays an important role in establishing that trust. Our nurses are there to advocate for them, help them build relationships with fellow providers, and educate them about their medical problems, Sippl says.
We approach these individuals in a positive and open manner and show them we are there to provide support and are not demanding anything of them, says Holly Bailey, FNP, of Santa Cruz County’s Project Connect. I provide education on self-care, prescribe medicine, or refer them to a clinic for ongoing care. Much of my time is spent educating my clients about their bodies, their illness, how to access resources in the community, and empowering them to be in control of their body, mind, and spirit.
Not Intervening Is More Costly
With the initial five-year funding now expired, the programs are seeking support through their local county sources and hospitals.
Goldstein says the initiative pays for itself through reduction in ED use and by adding the frequent ED users to Medi-Cal and Medicare. These are folks at the high end of the healthcare system in terms of complexity of problems, utilization, and avoidable costs. While it’s expensive to intervene, it’s more expensive to not intervene. Hospitals are seeing that it is definitely advantageous for them to intervene in terms of finances and medical management.
For more information on the practices and lessons learned from the initiative pilot programs, go to www.frequenthealthusers.org.