Short-term solutions with long-term benefits | Behavioral Healthcare Executive Skip to content Skip to navigation

Short-term solutions with long-term benefits

May 1, 2009
by Sharon L. Rapport and Lisa Mangiante
| Reprints
Providing frequent users of emergency departments with multidisciplinary services has dramatic payoffs

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:

  • Two-thirds have untreated physical conditions (diabetes, cardiovascular disease, cirrhosis, respiratory conditions, seizures, hepatitis C, HIV, chronic pain).

  • More than half suffer with substance abuse disorders.

  • More than a third have mental illnesses.

  • Almost half are homeless.

  • More than one-third experience three or more of these barriers.2

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