Health detectives use house calls, ‘hotspotting’ to cut costs

By Katie Kerwin McCrimmon

AURORA The red cross on the hospital emergency sign shines like a beacon of hope.

Some new refugees from Africa who are utterly perplexed by U.S. hospitals come seeking basic needs like food and diapers.

One Aurora man kept showing up at University of Colorado Hospital for a variety of medical ailments. Providers treated and released him, but over and over, no one figured out the root of his problem. Finally, a team from a new program called Bridges to Care visited the man in his home and the answer was obvious.

His sweltering apartment nearly suffocated them.

Yeah, its very hard for me to be home. I go to the hospital when I get too hot, the man told his care coordinator.

He was using the ER to cool down, said Heather Logan, co-director of Bridges to Care for the Metro Community Provider Network, the only system of safety-net clinics for low-income people in Aurora. He would go and accrue astronomical costs to stay cool.

So the team came up with an unconventional and much less expensive solution. They bought the man a swamp cooler, and his ER visits stopped.

Bridges to Care is an experiment thats part of the trend in health care called hotspotting. Dr. Jeffrey Brenner, a family physician working in one of the poorest communities in the U.S., Camden, N.J., pioneered the concept when he found that 1 percent of people there were racking up 30 percent of health costs. (Click here to read more: Hotspotting health revolution comes to Aurora.)

Brenner looked for hotspots or outliers in vast amounts of data the sickest people who were costing the most. Then he did the unthinkable. Instead of trying to cut off these complex patients, Brenner gave them more, better-tailored care. Teams of nurses and health coaches made house calls, accompanied the patients to doctor visits, streamlined their medications and helped them get well so they could stay out of hospitals. (Brenner this year won a MacArthur genius grant. Click here to see Brenner describe how hotspotting works.)

Care teams testing Brenners methods sometimes tap unusual cures like buying the Aurora man a swamp cooler or removing mold to alleviate a patients chronic asthma attacks. The idea is to give people intensive support for a short period of time, then help them graduate with a better sense of how to stay out of hospitals. They learn how to follow up with their primary care providers, how to take better care of themselves and to act quickly if complex health problems worsen.

Aurora is one of just four communities in the country sharing a $14.3 million federal innovation grant to implement Brenners model. The other pilot sites are San Diego, Allentown, Pa., and Kansas City, Mo. The three-year program overseen by Rutgers University in New Jersey started enrolling patients in Aurora in January and aims to save $70 million across all the sites.

Nobody ever cared before

The Aurora program targets four Zip Codes, two of which have the highest medical costs for Medicaid patients in Colorado. Those are 80010 and 80011. Bridges to Care volunteers are also targeting residents in the 80012 and 80013 Zip Codes. Just like in New Jersey, hotspotters in Aurora have found that a small number of high-need patients are generating most of the costs. Colorado Medicaid data show that 3 percent of patients are generating more than 50 percent of the costs. Finding those costly patients, improving their health and dramatically cutting their health care expenses could have revolutionary long-term impacts on health systems and drive down persistently rising health care costs. (Colorados Medicaid program is also using Accountable Care Organizations to try to find and help high-need expensive patients. Click here to read Better care grounds Medicaid frequent flyers.)

So far, Aurora, teams have enrolled 187 patients for the 60-day program. To qualify, patients must have visited ERs in the area multiple times in the previous six months. Most have multiple chronic health problems along with mental health challenges. Once patients join the program, they get at least eight visits from team members including mid-level nurses who can prescribe most medications, behavioral health experts and community volunteers from a neighborhood Catholic church, St. Therese, and the statewide interfaith community group, Together Colorado.

Through mid-October, 81 Aurora patients had graduated from Bridges to Care. Another 58 were participating in the program while about 41 have not completed the program, dropped out, moved or disappeared. The goal over the full three years is for Bridges to Care teams to work with 900 patients.

A provider comforts her patient during a home visit. Many of the Bridges to Care patients have previously undiagnosed behavioral health problems.

Early cost data on 35 patients who have graduated and been on their own for at least six months show both hospital visits and admissions are down.

Before signing up for the Bridges program, those patients on average had more than three ER visits each that cost $195,500. Visits are down and costs for those patients added up to $113,900. The savings for hospital admissions are even greater. Care in hospitals for the 35 patients cost $426,600 before they participated in the Bridges program and $121,500 afterwards.

Its too soon to tell if graduates will continue to stay out of hospitals.

But, its clear that patients welcome the personalized home visits.

The thing we hear quite a bit is that nobody ever cared before. Nobody ever asked me how I feel or took the time to sit down and ask me questions about my life. For many, its the first time they feel they have a voice, said Logan, the co-director.

The target Zip Codes in Aurora are full of people with major challenges.

Many are indigent, uninsured or underinsured. Many dont have Medicaid. They dont know where their next meal is going to come from. Transportation is not working. This is a high, high-need population, said Dr. Angela Green, co-director of the Bridges program and director of behavioral health for Metro Community Provider Network. Its high poverty, high crime, low resources.

Since residents are often transient, simply tracking each patient in the program can be a challenge.

Some who didnt complete Bridges to Care ended up in jail. Others were so severely ill that they had to go into hospice programs.

Unique to Aurora among the sites around the country that are piloting Brenners program is that all patients are receiving behavioral health care along with basic medical care. This choice makes Colorados program more complex. But, Green said patients are already benefitting.

Its much more than identifying patients with depression or schizophrenia, said Green. Its more encompassing. It has to do with things like parenting, compliance with medication or coping.

Behavioral health assessments can uncover childhood trauma, family stress or cultural habits related to health. If patients only got care in hospitals as children, for example, those people reflexively will continue to seek care in ERs. Care teams help patients focus on how their behavior can adversely affect their health.

Because the counseling visits are standard, the teams have been able to uncover underlying and previously undiagnosed behavioral health problems that are contributing to physical problems and thus to expensive ER visits.

For instance, the first patient enrolled in Bridges to Care was an African refugee who had just had a baby. She was suffering from chronic breast infections that were interfering with her ability to breastfeed her newborn. The home visits then revealed much more complicated problems.

Our nurse practitioner felt that something wasnt quite right in the relationship between the mother and baby. The baby was never there. The father was always the go-between, Green said.

The nurse practitioner immediately sent a behavioral health expert to do a follow-up home visit. That appointment uncovered a common and potentially dangerous problem.

The mom was having some significant post-partum depression, Green said.

Partly because of language and cultural barriers, the patient had not understood how to properly treat her infections. Isolated and ill, her depression worsened.

I think it blindsided them, Logan said. In the hospital, doctors were asking her questions. But she didnt feel comfortable answering them because she felt it was disrespectful to her husband. So, we started working with the husband.

Through the husband, the team was able to help the family understand what was going on, that depression is common for new mothers and that they could help.

In their particular culture, they wouldnt call it depression and they wouldnt treat it the way we would treat it. They had no other family or friends here yet. It was really important to make that connection, Green said.

Weve been able to catch people we wouldnt have otherwise caught, she said.

In all, more than 50 percent of Bridges to Care patients so far have had previously undiagnosed mental or psycho-social problems. For the refugee, treating the depression helped resolve the infection and proved critical to the infants well-being.

The therapists went in and by the end, the mom was caring for the child. The visits consisted of the whole family sitting together on the couch and the baby was in the mothers arms.

A knock on the door

Hotspotting takes patience and the right workers. Most patients live in extreme poverty. Their lives can be a mess.

Lily Juan is a family nurse practitioner who conducts home visits for Bridges to Care, then follows up and sees many patients in the MCPN clinics once they graduate. Irrepressibly positive, Juan grew up in Taiwan, studied nursing at the University of Texas in Austin, then moved to Colorado specifically to work for the hotspotting program.

Lily Juan is a family nurse practitioner who visits patients in their homes. Many have complex health problems and live in poverty. Juan treats each of them like a family member.

One of the secrets to her success may be her personalized approach.

I treat them like my family, Juan said of her patients.

During a day of house calls this fall, Juan visited a patient who had wound up in the ER after a suicide attempt.

Juans mission on this day was very basic. She needed to be sure that the patient had pulled out of her crisis and was taking her medications.

Juan punched the patients address into her GPS, which guided her to a complex of low-slung apartments. She unloaded a rolling cart full of medical supplies and walked fearlessly to the door. (On all first visits, Bridges to Care workers go in pairs to ensure their safety. If they have any reservations about follow-up visits, they bring a co-worker or meet a patient in a more public setting.)

A medicine bottle sits on the floor at a patients apartment. Many patients live in poverty.

Juan pulled her cart to the second floor apartment door and knocked. At first, she got no reply. She knocked again and a groggy woman answered. The woman had forgotten the appointment. That wasnt a good sign.

Neither was the disarray. Pill bottles and dog food littered the floor. An open jar of peanut butter and some crackers sat next to video games near the TV. On the floor in the crowded living room, a mat stood ready for the womans dog to relieve himself.

Undeterred by the chaos, Juan opened the blinds and turned on some lamps so she could see. Then she cleared some space on a dirty white couch and started her exam.

She took the womans vitals and asked her about the Bridges to Care folder where the patient is supposed to be keeping all her paperwork. The woman looked confused. Juan reminded her about the forms and urged her to keep a diary about how she was feeling.

Thats your homework. The more you write down, the more it will help me.

Juan then checked the womans medications, ensuring that she didnt have too large a supply to prevent another overdose.

Lets talk about your headaches, Juan said, as she read the womans health records.

It feels like my heads in a car compactor, the woman said.

Thats pretty standard for a tension headache, Juan said.

The women discussed how best to treat the headaches. Then, as the womans dog jumped into her lap and she fussed over him, Juan brought up the most important issue of all.

I saw that you are actually thinking about killing yourself. Can you tell me more about that?

As part of the Bridges to Care program in Aurora, Lily Juan visited a patient who had been suicidal. The woman was still struggling, but Juan was relieved to find her patient interacting happily with her dog.

The patient said she had been pondering it. I have chronic suicidal thoughts. Sometimes I think, Wow, it would be so much easier if I was dead.

Juan pressed her. Have you had those thoughts today?

The woman shook her head and Juan remarked on that small victory.

Today, if you dont have that kind of thought, thats an improvement.

Then Juan extracted a promise.

Can I get your word that you will not take so much Tylenol again? Can I also get your word that if you get these thoughts again, you will call 911?

The patient nodded. Juan completed her exam. She wrapped up with a conversation about sleep and exercise.

Can you try to just walk around the block? Maybe next time we should do it together, Juan said.

Then she set a date for next home visit, packed up her cart and headed out the door.

To an outsider, the woman did not appear to be doing very well. But Juan walked out confident that her patient was improving. Yes, her house was in disarray, especially compared to the last visit. That was an indicator that she had gone through a period of deep depression. But Juan felt certain that the woman was not in imminent danger. How could she tell?

The woman had been playful and kind to her dog. The animal awakened some enthusiasm in her. Her interactions with the small creature indicated to Juan that the patient was safe for the moment.

Let us help you

Later that afternoon, Juan visited another woman in the Bridges program. This time, physical pain was overwhelming the patient.

Angela Hernandez, 43, has had multiple ER visits after she tripped and fractured her left ankle one night at her home.

Juan and all Bridges to Care providers work closely with Emergency Department teams at the University of Colorado Hospital and the Medical Center of Aurora.

Juan had reviewed digital records from University and found that her patient had been non-compliant with post-surgical instructions. Put simply, she was doing a lousy job of caring for herself.

Juans mission was to reverse the slide before the woman wound up back in the hospital.

When Juan arrived at the second-floor apartment, Hernandez answered the door carrying one of her grandchildren. She wasnt supposed to be putting any weight on her foot, much less lugging a toddler around.

Tears streamed down Hernandez face as she complained of the pain.

Yesterday, it was so bad, I was screaming, Help, Hernandez said.

Juan saw the swelling and wasnt surprised that her patient was in pain. She jumped into action, immediately sending the toddler off with his grandfather, getting her patient to recline on her couch with her legs propped on pillows and improvising with a quick trip to Hernandez kitchen.

Right now, the priority is to reduce the swelling, Juan said as she poked around for some frozen vegetables to place on Hernandez ankle.

I dont mean to be harsh, Juan said. But if the fracture isnt healing, you will not be able to walk.

Thats what I need to hear, the truth, Hernandez said, writhing in pain.

Then she turned to me and said how grateful she was for Juans help.

I love her. Shes really good.

Hernandez regularly cares for a trio of grandchildren who are 4, 3 and 9 months old. One of her grown daughters lives with her. She said she cant take time to heal. Its been a pattern shes endured her whole life.

Im a survivor. Ive never had a silver spoon, Hernandez said. Its been very rough. I was on the streets by myself at 13. My dad was a gambler. One day, I wake up and he and my mom were gone. I was the baby of 10. I was in the seventh grade when they left.

Hernanadez married at age 15 and had four kids. She said she has suffered from a series of health problems ranging from back problems to anxiety ever since.

When she got the call about Bridges to Care, she said she was stunned that someone would want to come help her in her home.

I was amazed, and in the beginning when you guys said you had all the behavioral and mental health care, I thought, Wow. Where did all of this come from?

Hernandez said she has seen therapists in the past to handle anger at all the people who have hurt her. She loves the Bridges to Care counselor and said shes grateful to get more therapy.

It just fell into my lap. I cried and said, Thank you Jesus. I was so stressed. I felt like I was going to lay here and die.

She also responds well to Juan who gave Hernandez and her family members stern warnings that it was critical for her to prop up her feet all day and stop taking care of everybody else.

Let us help you, Juan said. I really want you to feel better.

Detectives and health educators

Visits can be as short as 15 minutes or as long as two hours. Hotspotting is expensive and intensive on the front end, so the Aurora experiment is aimed at finding the best way to do the work at a reasonable cost. Juan takes the time she needs with each patient, but is always cognizant of the need to be efficient so the system will be sustainable.

Team members meet frequently to report results, share successes and brainstorm about failures.

Juan dealt with one tough case recently when a man with psychiatric problems abruptly dropped out of the program.

The man had been suffering from hallucinations and was at risk for suicide. He had sought care in the ER multiple times, usually complaining of stomach pain.

When I went to see him during the first visit, he was very quiet. He had been out of his psychiatric meds. We got him help really quickly, Juan said.

On top of the mental health problems, the man told Juan that he was doing meth and using other amphetamines. Care coordinators were working on getting him help.

Then, he moved from Aurora to Denver.

Oh, great. What do I do? Juan recalled thinking. We have the best team. We are really here to help. My biggest frustration is when we offer the help and they dont take it. We cannot force him to see someone.

Bridges to Care workers dont let patients just disappear. They try to find them and bring them back to the program.

A care coordinator tracked the psychiatric patient down in Denver, but couldnt persuade him to come back to the Aurora program. She gave him a list of resources, then had to let him go.

While failures can be dispiriting, Juan said victories are uplifting.

One came when the team worked with another man who had been in the ER multiple times. It was clear that he had substance abuse problems, but when Bridges to Care workers started visiting the 40-year-old man and brought in a behavioral health expert, they found that he had probably been suffering from schizophrenia for many years and never had been diagnosed. Now he is getting mental health services and is improving.

ER frequent flyers a complex conundrum

Solving the mystery of why so-called freqent flyers visit hospitals again and again can be a challenge.

One key, however, seems to be the old-fashioned house call.

Going into somebodys house can be a vulnerable place. But its a very eye-opening place, said Bridges to Care Co-Director Heather Logan.

A family of 10 may be living in 800 square feet. People are sleeping on the floor. Theres a tiny refrigerator and a hot plate. You can see why people end up in the hospital sometimes if they dont have a clean place to live. Hygiene can get bad. When youre just in the ER, you dont get to experience any of that.

When you go into the home, its a totally different ballgame. I see that you have a walker and you live on the fourth floor. I see it takes you 45 minutes to get upstairs, Logan said.

A 57-year-old Aurora woman celebrated her graduation from Bridges to Care with a party and flowers. Reluctant at first to participate, she ultimately embraced the program, improved her health and lost 18 pounds in eight weeks. (Photo courtesy Bridges to Care.)

Care team members need to be both detectives as they figure the source of health problems and educators who teach people how to change their behavior.

When you sit down with someone and ask, Whats driving you to the ER? its not always what you expect, Logan said.

For instance, the many immigrants now settling in the target Zip Codes come from diverse locations including Bhutan, the Ivory Coast and Nepal.

As Bridges to Care workers have learned more about these refugees, they have found that confusion about the American health system spawns many unnecessary hospital trips.

Newly-arrived Africans, for instance, are leery of clinics, but have great trust for hospitals. U.S. workers want to teach the refugees the opposite behavior: to avoid expensive hospitals and instead seek care in lower-cost clinics with primary care providers.

In many of the refugees home countries, hospitals are government run. That means they are the places where patients can seek the most affordable care. Sick people may have to line up and wait days, but eventually, they will get help.

In contrast, refugees say many clinics in Africa are privately run, profit-motivated centers that they say will hit you up for cash. To them, it makes perfect sense to avoid a clinic and go instead to the hospital.

We have a high number of refugees who are being resettled. They dont speak English. They are not familiar with the American culture. They see the red cross on a hospital emergency sign and know that if they go there someone will help them with what they need, said Bridges Co-Director Angela Green.

On top of confusion about hospitals, few refugees understand the concept of preventive care.

Theyre waiting until their foot is incredibly infected before getting help. The whole concept of refilling medications ahead of time so you can take care of your diabetes is foreign to them, Logan said. They wait for that crisis situation. Instead of going to a clinic, they end up in a hospital where costs are astronomical.

By the time patients graduate from Bridges to Care, they have a basic understanding of complex U.S. health systems, and most importantly, a relationship with a primary care provider.

We see a confidence level. People know what to do, said Logan.

Workers make a big deal when patients graduate. They give each a goody bag. It contains checklists so theyll know how to take better care of themselves and what to do if they get sick or need help. Many patients are working on eating better and moving more, so each gets a pedometer and a Nalgene water bottle. They get some lip balm, all the right phone numbers for clinics and relevant programs, such as Arapahoe House for people with substance abuse problems. And, graduates all get bracelets with a thumb drive so they can carry their health records from place to place. Ideally, if providers keep the thumb drives up to date, they can become a valuable communication tool between disparate hospitals, health systems and various treatment programs.

It can contain paperwork, discharge summaries and medication lists, Logan said. If the patient says, I dont know what University told me, it can be a valuable tool for providers. They can just hand the thumb drive to a medical provider.

Reluctant participant, proud graduate

One woman was so proud to graduate that she held a party and invited friends and neighbors to celebrate. Her excitement marked a profound change. The 57-year-old had visited the University of Colorado Hospital four times in May and June of this year and at first, turned down requests to join Bridges to Care. She suffered from a variety of health problems including hip and back pain and chronic lung diseases that were causing shortness of breath.

Once she enrolled, the womans turnaround was remarkable. Despite hip pain that makes it hard to exercise, the patient lost 18 pounds over eight weeks, lowered her blood pressure and improved her lung health. She now is seeing providers at Aurora Mental Health. Bridges to Care workers were disappointed this fall when the patient showed up one more time at the ER. Still, they hope she has learned to seek most of her care in other settings.

Candie Nunez needed inexpensive blood pressure medicine and had nowhere to get it but the University of Colorado Hospital Emergency Department. Then she joined Bridges to Care and finally got the health care she needed.

Another graduate is Candie Nunez.

Bridges to Care found me. I was going to the ER quite frequently for my blood pressure pills. I had no doctor here, said Nunez, 51.

She had moved to Aurora from Las Cruces, N.M., to care for an older sister who was severely ill.

Nunez needed refills for simple blood pressure medications that should have cost as little as $4 a month. But she couldnt find a doctor to care for her and prescribe her medication.

She tried to get in to the Metro Community Provider Network clinics and found there were waiting lists.

I would call every morning at 7 to see if they had an opening to get a primary care provider, Nunez recalled.

She said she struggled most of last year to get care. The ER was the only place she could turn for help.

I would tell them, Im sorry I have to come in here. Can you at least give me three months of (blood pressure) pills? I got billed for all of them. Some are like $700 or $900.

She said shes uncertain exactly how much debt she now owes for the hospital visits.

I kind of dont want to know, said Nunez, who ironically used to be a hospital clerk when she lived in Texas.

She used to have health insurance and was quite healthy until her blood pressure began to spike. Then, on a trip from Texas to New Mexico five years ago, Nunez brakes gave out on a hill and her car smashed into a truck ahead of her. Her right leg was crushed in the accident, but she never received treatment and now walks with a pronounced limp and experiences both numbness and pain.

When Bridges to Care workers called her, Nunez leaped at the opportunity to join.

Yes, please. Ill do anything to get a doctor, she recalled thinking. My prayers were answered.

Finally, she got help with her high blood pressure and found that she had been taking the wrong medication. She also saw a dietician and a behavioral health expert.

They all came. It was great. Ive never felt pampered. Ive never even thought about having all those different kinds of people come see me. They answered questions. They were very polite and got to the bottom of things, Nunez said. I was shocked at all the help.

As part of the program, community members also visit Bridges to Care participants. Rich McLean is a volunteer from St. Thereses Catholic Church who works extensively with Bridges to Care. He shakes his head when he hears Nunez recount her struggles to get help with something as common as high blood pressure.

Its too bad it has to be a special program. This should be normal, he said of the care Nunez finally received.

Once enrolled in the program, Nunez also found that her cholesterol was high and now shes avoiding salt and deep fried food.

Im eating better. I bake everything, she said.

After graduating, she was able to get the primary care she needed, including dental care and a long overdue mammogram.

The only problem now is that she cannot get specialty care so she cant get her leg problems resolved.

Its not broken, but they cant tell me whats wrong, Nunez said. It collapses. Maybe the tendons are torn. It hurts from my hips to my toes. I need to see a specialist. I know Im going to have to have some kind of surgery. I just cant get that help.

Nunez may qualify for Medicaid as coverage is expanded in 2014.

For now she also prays for expansions of programs like Bridges to Care so people like her can receive basic help. Without it, she said the struggle can be overwhelming.

Its almost like youre invisible.