Laura Ungar
Courier-Journal
In less than two years, Dennis Manners was treated 337 times at University Hospital’s emergency room — sometimes after passing out drunk in the street and being brought in by ambulance.
Usually, it wasn’t an emergency. But Manners nonetheless racked up $626,143 in charges he couldn’t pay.
Then hospital officials stepped in, enrolling Manners in a new program that aims to stop the inappropriate use of the emergency department by such costly “super-utilizers.”
For about $6,000, they found the 54-year-old formerly homeless man a primary-care doctor and a neurologist to treat a seizure disorder, got him into a substance-abuse treatment and helped get him an apartment.
“What we did was, we sobered him up,” said nurse Barbara DiMercurio, director of emergency services. “We decided enough was enough.”
DiMercurio said University Hospital’s Population Health Management Complex Case Program, launched in August and influenced by a similar initiative in New Jersey , has so far helped 18 patients like Manners, and is in the process of enrolling others.
Thus, DiMercurio said, the complex case program saves taxpayer money. So far the hospital has spent about $18,000 on all program participants, helping six at a time.
Dr. LaQuandra Nesbitt, director of the Louisville Metro Department of Public Health & Wellness, said she supports such programs and expects to see more in the future.
“Back in the day, we’d say, ‘Treat ’em and street ’em,’ ” she said. “But now, hospitals are realizing the need to deal with these (social) issues” that bring people back again and again.
Since joining the program eight months ago, Manners has been back to the ER only three times — twice for seizures and once for high blood pressure. He said he’s grateful the hospital helped him get his life in order.
“It’s a gift from God,” he said. “I was out there, and I didn’t have anything. Now I have a chance.”
A national issue
University Hospital’s program addresses a nationally recognized problem: ERs often serve as a last resort for the uninsured poor across the United States.Federal law says that ERs must see patients and provide stabilizing treatment for an emergency medical condition regardless of someone’s ability to pay.
So people who don’t have access to doctors in the community often seek help at an ER. Kentucky and Indiana have higher-than-average rates of ER visits overall; the Kaiser Family Foundation says Kentucky had 549 visits per 1,000 people and Indiana had 491, compared with a U.S. average of 411 per 1,000.
But studies have shown that having a “medical care home,” such as a primary-care office or clinic, reduces inappropriate emergency department use significantly. It also saves money.
According to the federal Medical Expenditure Panel Survey, the median ER visit cost $615 in 2009, compared with $361 for a visit to an office-based physician.
In Camden, N.J., an approach called “hot-spotting” — which influenced the creation of University Hospital’s program — sought to get more people into medical homes.
There, Dr. Jeffrey Brenner formed a nonprofit group and put in place a model to increase coordination of services for “super-utilizers.”
The model, supported by the Robert Wood Johnson Foundation, aims to move those patients from the hospital to outpatient care and ensure they get other services they need.
Almost daily visits to emergency room
Manners, a longtime alcoholic, said he used to wash dishes at Churchill Downs, but after having a seizure he couldn’t work.He said he became homeless about four years ago and for a while was coming to University’s ER almost daily, about half the time by ambulance.
“I was drinking too much. I came here to sit, and they came to me and helped me,” said Manners, who is uninsured.
Dr. Adam Whiteside, a third-year medical resident who treated Manners, said he sometimes suffered from malnutrition, dehydration and spiking blood pressure. But often, his medical issues could have been handled better by getting regular care from doctors in the community.
“Obviously, in the ER we have a lot of people who have a real emergency,” Whiteside said. “It does stress the system.”
Manners was an ideal candidate for the program. Criteria for enrollment include having five or more ER visits in three months and charges exceeding $500,000. Participants are identified by staff based on medical history, frequency of visits and a willingness to make lifestyle changes.
DiMercurio said Manners underwent the first five days of alcohol detoxification at University Hospital, which paid for additional detox and treatment in a 90-day program. When he finished, they sent a cab to take him to a transitional program through Volunteers of America.
They got him a doctor at Family Health Centers’ Phoenix Health Center for the Homeless, where he gets regular care and checkups once a month. He also sees a University of Louisville neurologist. All of the medical care is free to him.
Officials helped him get a free apartment through a grant from Rx:Housing, a national movement to find homes for 100,000 vulnerable homeless people by midyear. They took him to the food stamp office to sign up and helped him with a claim for Social Security Disability, which is pending.
“They was good people,” Manners said. “... I thought my life was over. Now, I’m venturing out and doing better things with my life.”
DiMercurio and nurse Patti Stivers keep in touch with Manners’ family members, who help keep him on the right path.
Rashida Weber, Manners’ 30-year-old niece, said the family had been estranged from him when he was drinking and living on the streets.
Now, they take him to church and 12-step meetings, invite him to Sunday dinner, and check on him regularly. Weber said her four children barely knew him before, and recently, her 11/2-year-old daughter grabbed his hands and prayed with him in church.
Manners’ sister, Dorothea Lemmons, said she believes her brother is finally determined to stay sober and healthy.
University Hospital’s program “has been a blessing. That’s the simplest word I can use, and the most powerful,” Weber said. “He needed to know that he had support. ... (DiMercurio) saw beyond the labels, and had a belief in him.”
Looking to expand
DiMercurio said University Hospital hopes to expand its program. The hospital has no budget specifically for the complex case program, using money from the ER budget, she said, but officials hope to formally budget the program for the next fiscal year.On a recent afternoon, DiMercurio and Stivers began the process of enrolling a new frequent ER patient, 58-year-old James Gaskins, into the complex-case program. Gaskins, a Vietnam-era Army veteran, said he’s been homeless and abusing alcohol for years.
He said he has liver problems, is legally deaf, has a crushed right foot after being hit by a car, and recently had a heart attack.
“I think he’s a great candidate for the program,” said Stivers, a clinical navigator for the population health program. “He’s willing to change.”
Gaskins agreed.
“I’m tired of living on the street drinking. I’m trying to get sober,” he said. “I think this program is great. They’ve done more for me than anybody else in this town.”