Recently, Dr. Rodney Hood sat down with a 50-year-old man who'd been in and out of the hospital and ER 45 times in the last two years. The man suffered from chronic lung disease, congestive heart failure and diabetes.
They talked for about 45 minutes, "just trying to figure out what was going on," Hood says.
The patient, a former smoker, has trouble breathing. He lives with his mom and two other family members, both of whom smoke.
"So, he's in a house where folks are smoking, he's on a whole lot of medications, and with his low oxygenation and whatnot, it became clear to me he's real confused about his medications and does not appear to take the medications regularly. He thinks he does, but it's clear he forgets to take them sometimes," Hood says.
The man can't afford to move into his own place. But staying put means more hospital visits for problems that likely wouldn't exist if he were in a different environment.
Hood's patient is what's referred to as a "super-user."
"There's 1 or 2 percent [of patients] that probably consume 30 or 40 percent of the funds that [Medicaid and Medicare] spend," Hood says. "The highest costs are usually in the hospital and ER, so, by identifying those 1 or 2 percent, putting together a plan that would minimize the utilization of hospitals and ERs, all of a sudden... there is a financial model that makes sense to take care of these patients."
In June, San Diego was one of five urban areas to receive part of a $14.3-million grant from the Center for Medicare and Medicaid Innovation (CMMI) to develop a strategy for managing "high-cost, high-need" patients like Hood's—low-income folks with chronic conditions, like diabetes, asthma and heart disease, that could be brought under control with the right treatment plan. In this man's case, that treatment plan would involve the help of a social worker to see if he qualifies for housing assistance.
"Is there some type of independent-living facility where he can go?" Hood says. "What is he eligible for? What is he not eligible for? He also needs oxygen; he doesn't always have the oxygen. We would arrange to make sure that he did. We would have someone going out on a regular basis, monitoring his medicine initially every day if necessary; we would make sure he had what I call VIP access' to his primary-care physician, so if he called up and said, I'm not feeling well,' we would see that he would get in the next day, and if he needed a breathing treatment, he would get it there, rather than waiting two or three days and he winds up in the ER."
The grant comes out of a model developed in Camden, N.J., by Jeffrey Brenner, a young family-practice doctor whom Atul Gawande profiled last year in The New Yorker. In a piece called "The Hot Spotters," Gawande looked at Brenner's Camden Coalition, a team of medical and socialservices providers who set out to find, and treat, Camden's super-users of hospitals and ERs. The term "hot spotters" comes from the police practice of using mapping software to pinpoint high-crime areas and target resources, something Brenner learned about while serving as a citizen member of a police-reform commission. Brenner realized he could use the same mapping tools to find patterns in 911 medical calls and wondered how much money could be saved if resources were focused on intervention and preventive care.
Targeting frequent users isn't a new concept for San Diego. For an 18-month period in 1997 and 1998, Dr. Jim Dunford, medical director for the city of San Diego, tracked ER usage by 15 homeless chronic alcoholics and found that their ambulance and hospital bills alone—they made 417 visits—came to $1.5 million. This led to the creation of the city's Serial Inebriate Program (SIP) in 2000, which gives chronic alcoholics the option of treatment instead of jail.
In 2010, the United Way of San Diego County launched Project 25, a three-year pilot program aimed at identifying 25 chronically homeless "frequent users" of medical and public-safety services and showing that by putting them into housing combined with case management, costs would shrink dramatically. Indeed, data showed that Project 25 participants cost taxpayers, on average, $317,000 each per year prior to enrolling in the program and roughly $95,000 each after.
"One of the philosophies which I think the Obama administration rightly agrees on"—the CMMI grant is part of the Affordable Care Act—"is you've got to go after the most expensive issues first. You can learn the most by solving those problems," Dunford says.
The program created under the grant will focus on Southeast San Diego and National City, two areas identified as having significantly higher-than-normal hospitalization—and death—rates from manageable diseases, like diabetes, asthma and heart disease. Under the grant, a team will identify 200 super-users of medical services and hook them up with comprehensive care.
The Multicultural IPA, a group of physicians working primarily in central and Southeast San Diego, National City and San Ysidro (Hood, who's practiced medicine for 30 years in Southeast San Diego, is the organization's president), is overseeing the grant along with the San Diego Organizing Project (SDOP), which helped put together the data to identify the county's hot spots.
"We've been poking around this issue of chronic disease among African Americans and Latinos in these communities," says SDOP organizer Hannah Gravette. "We believe there are ways to create savings simply by rearranging the way we deliver care in this country and the way we engage high-cost, high-need patients. This has already been proven by Dr. Brenner in Camden."
SDOP does community outreach through churches, which proved to be powerful resources for the Camden Coalition.
"There's a group of us who went to Camden," Dunford says. "We went to the Baptist church, and it was incredible. You've got Baptist ministers and preachers with graphs and charts talking about healthcare costs." Dunford describes churches as an "uptapped resource" in improving healthcare. So, too, are barbershops.
On a recent Friday morning, every seat at Mario Lewis' Imperial Barbershop in Encanto was filled. Healthcare, Lewis says, dominates the conversations in his shop, partly because some of his customers' health is so poor.
"We have customers coming in here losing limbs because of diabetes, on all types of medication," he says.
Lewis is the president of 100 Strong, a community group of African-American business owners, which, with Hood's help, is launching its own project called the Men's Health Initiative. Participants will get an initial health screening that checks markers like blood pressure, weight and cholesterol. They'll then set goals for lowering those numbers and keep a journal for six months to measure their progress.
"We're going to have support groups; we're going to have exercise classes, nutrition classes," Lewis says.
He admits it might be tough to change people's habits. Though, like with Dr. Hood's patient, environment is partly to blame.
"We don't have the freshest food," Lewis says of his neighborhood's lack of grocery stores. "People around here who don't have vehicles have to shop at the liquor stores . It hurts me when I see a family shopping for vegetables in a liquor store. It doesn't make sense to me."
Lewis recently became a vegetarian.
"For me to get a fresh salad, I have to drive all the way across the 805 to Sizzler. I can't find one within a two-mile radius. That's crazy."
100 Strong is helping build a community garden, where families can buy plots for a small annual fee. Lewis sees it as a start—and, ideally, part of the larger system Hood, Gravette and others envision with a more holistic, proactive approach to healthcare.
"We need an accountable system to allow the patient to make accountable decisions," Hood says, "and our system right now is fragmented—it's based upon whether you have money or whether you don't have money, and the less money you have, the more difficult it is to access what you need. So, what I see us doing is trying to build a system that is more accountable, putting the patient in a position where they can become accountable."