The Bridges to Health makes emergency room ‘frequent fliers’ healthier while reducing visits to the hospital.
By Nancy Wang
Go to any hospital emergency department on a weekday afternoon and you’ll most likely see variations of the same sight: patients outnumbering doctors and beds. Some of those waiting will ultimately get admitted to the hospital for surgery or other care, but most will be given a temporary solution and told to see their doctor. For the patients who don’t have a regular doctor or the money and means to see one, the ED becomes an all-too-familiar place.
This misuse of hospital resources is one of the major contributors to health care overspending in America. While providers, patients and even lawmakers agree on this fact, what to do about it is less clear.
Dr. Steve Crane, a family-medicine doctor from Asheville, is one of the people working on finding a solution.
For the past two and a half years, Crane has spent two days a week running a free group health clinic in Hendersonville. Unlike most free health clinics, where a wide variety of people are seen individually and most people rarely come more than once, this one works exclusively with a group of 44 local residents and each visit is conducted as one large group visit.
Participants sit together and talk about their problems. Most of the participants suffer from chronic pain, mental health issues and substance abuse. The clinic is part of a program called Bridges to Health, started by Crane to address emergency department misuse.
In 2009, Hendersonville’s Pardee Memorial Hospital ED serviced approximately 45,000 patients. Among those were 255 patients who used the ED six or more times, racked up more than $3 million total in unpaid medical bills and were unable to pay. They were all uninsured, low-income patients, many with a history of substance abuse or mental health issues. Most of those ED visits, Crane said, were for issues that would be better addressed with long-term continuous medical care than short, fragmented ED visits.
“Many of these people just went to the ED because they were in pain or scared and didn’t have anywhere else to go,” Crane said. “You see them going back so many times because their real issues are not supposed to be treated in the ED and are not taken care of.”
With Bridges to Health, Crane aims to decrease ED expenses while providing the right type of care for this subgroup of patients. He describes the program as a patient-centered medical home on steroids, meaning that patients receive integrated care from family medicine doctors, behavioral health care providers and a nurse case manager, working together to meet each patient’s needs. Crane and his team were able to contact 147 of those 255 patients identified as ED over-users, with 44 subsequently enrolling in the program.
The program’s free clinic is part medical check-up, part group therapy.
Crane said that while the doctors treat rashes, abdominal pains and other symptoms, the patients often provide more valuable help to one another, suggesting, for example, which lawyers to call for legal assistance or where to eat or sleep inexpensively.
All visits, labs and medications are free, and each participant is given a $5 food voucher and a bus voucher. Thus far, the program has been operating on a $55,000 annual grant from N.C. Health Net, a branch of the N.C. Department of Health and Human Services.
The health care team encourages participants to come to as many group clinics as possible, even if they are drunk or high.
“A lot of people isolate themselves and think that no one understands what they are going through,” said Lori Collins, the program’s nurse case manager. “I think we give them hope just by talking and listening to them and helping them meet other people who are going through similar struggles.”
One participant, Nancy Foltz, struggled with post-partum depression and bipolar disorder for 15 years before joining Bridges to Health in 2010.
“Before the group, there were days when I felt so sick, and I couldn’t see anything good in the future, that I just wanted to be dead already,” Foltz said. “This group and program was a place to go and be safe, be heard and be taken care of. If it wasn’t for the group, I don’t think I would be speaking to you today.”
One of the first participants enrolled in the program, Foltz has remained a regular and reports that she is now on steady medication and feeling better than she has in decades.
“Unlike in AA or NA, we’re not a program that is anonymous,” Foltz said. “Even though what we say in group stays in group, the bond is stronger than that and a lot of us look out for each other even outside of the clinic.”
By the end of the program’s first year, 10 participants who frequently attended the clinic found some form of employment and six of seven who were homeless found stable housing. The program also boasted success in decreasing ED expenditures.
When the program launched, participants were averaging roughly seven ED visits a year, costing an average of $14,004 per person. At the end of the first year, that dropped to an average of roughly three ED visits a year, costing an average of $2,760 per person. This amounted to $404,784 in savings for the Pardee Hospital ED.
Data for the second year is still being analyzed.
While the results of the program are very promising, Crane points out that the group of 44 is small, and that the clinic really only works for those participants who make the effort to come to the meetings.
He and his team, however, are hopeful that programs like Bridges to Health will gain more support. He believes that targeted programs that provide continuous and integrated care to people who are at high risk for medical, mental and social problems are not only a solution to the financial issues with health care in America but offer a better way of providing care altogether.
“The current regular care we provide these people can be dehumanizing, and this program humanizes them,” he said.
There are plans for a Bridges to Health pilot to be replicated in Charlotte sometime this year, with a few other North Carolina and Virginia counties hoping to also get on board.