By Melinda Young
As any case manager knows, preventing readmissions and ED visits by the most at-risk patients is an enormous challenge. It requires addressing all the social determinants of health needs they may have, as well as finding creative and affordable solutions.
“We invested in the patient up front, providing all those services we felt could make a huge impact on their hospitalization,” says Pouya Afshar, MD, MBA, chief executive officer and co-founder of Presidium Health in San Diego.
The following are case study examples of how an innovative team of primary care physicians (PCPs), case managers, and others can help people break the cycle of returning to the ED and hospital whenever they need medicine or experience preventable chronic illness crises.
• The woman who lived in her car. Afshar worked extensively with a middle-aged, obese patient who lived out of her broken-down car. She was diagnosed with multiple comorbidities that required strict adherence to a daily medication regimen.
Whenever the patient needed a medication refill, she borrowed someone’s phone and called for an ambulance. The ED staff would test her, see that her health was poor, and then admit her to the hospital. She eventually would be discharged with her medication in hand. But her repeat visits due to a lack of access to medication cost $400,000 per year, Afshar says.
When the hospital-at-home program found the patient, their first action was to get her a cellphone. Then, when they realized she had no way to charge the phone, they spent $18 on a solar charger. They also provided food delivery and connected the patient with a personal trainer to help her get back on the path of exercise and better lifestyle choices.
The team connected the patient to a mechanic to get her car functional, licensed, and registered so she could drive it. They put a small portable refrigerator in the car, plugging it into the car battery.
“We’d have to check the battery regularly and get her a new one when needed,” Afshar says.
The patient already arranged with someone on the street to shower in their house periodically. With the team’s help, this was all she needed and wanted.
“In the course of a year, she had two hospitalizations that were COVID-related,” Afshar says. “Her cost of care went down to $26,000 per year.”
One of the care coordination lessons from this case was that not every patient can be placed in traditional shelters and other housing for the homeless. “We have this thing in our organization that you have to meet the patient where they’re at. She didn’t want to go to a shelter; she didn’t want to be confined and limited in what she could do,” Afshar says. “That didn’t work for her.”
Other patients were interested in housing options, but not everyone is ready for that. “[The patient] just wanted to be taken care of where she was at, and for her, that was her car,” Afshar explains. “We had medications delivered to her and had labs done in her car.”
Since the patient was eating unhealthy fast food, they arranged for diabetic-friendly food to be delivered to her.
Afshar visited the patient and spent time with her to build trust and assess her challenges. That is how he learned that her most immediate need was a cellphone and a working car.
• The patient with asthma in a smoker’s home. Another person the team cared for lived in a subsidized apartment with nine people, mostly smokers — except the patient, who has severe asthma.
“Most of her hospitalizations were for asthma exacerbation, and she was hospitalized two to three times a month,” Afshar recalls. “Historically, she had been given nebulizer treatments and medication.”
It took the team three months to convince someone in the patient’s household to open the door and allow them to enter. They were skeptical of any visitors because their apartment was overcrowded according to the government rules.
“We built trust with them and told them we were there to help,” Afshar recalls. “When they let us into the house, the first thing we saw was there was a lot of smoke in there.”
The team told the patient that she could not live in a home with smokers because of her disease. “It hit me right away,” Afshar says. “I could give her all the medications she needs, but unless she got out of that environment, she would have problems with her asthma.”
They found alternative housing for the patient in a smoke-free environment. It resulted in immediate improvement of her asthma symptoms.
• A patient with poorly managed schizophrenia and chronic illnesses. A woman in her 60s diagnosed with severe paranoid schizophrenia visited the ED several times a week — sometimes even twice a day.
Whenever an ambulance arrived at her home, EMTs noted her high heart rate. They would take her to the ED, where she was given beta-blockers and sent home.
“It took us two months to come into her house,” Afshar says. “When we did, we found she wasn’t taking any of her meds. There were six to seven months of bottles completely unopened. These were to control her blood pressure, heart rate, and schizophrenia.” The woman had received medication through mail-order prescriptions, but she never used them.
The challenge was to gain the patient’s trust and convince her that she needed to take her schizophrenia medication because it was the key to improving her adherence to her other medications.
“We found the key was to understand what she was interested in,” Afshar explains. “When we walked into her house, we found a lot of beautiful artwork. I asked her where she got it, and she said she made it. I asked her if she was still making art, and she said no, because she didn’t have money for the supplies.”
That was the way to gain the patient’s trust. “We spent $300 on pens, sketch pads, and so forth. She became entrenched in her art and began to trust us,” Afshar recalls.
The team asked the patient to start taking her medication. They arranged for a monthly injection for her schizophrenia medicine. Soon, her behavior changed, her mood stabilized, and she became more interactive.
“Then, we convinced her to take her blood- and heart-controlling medications,” Afshar says. “The icing on the cake was she ultimately needed an ablation procedure to control her heart rate issues.”
It took the team a year to gain the patient’s trust and chip away at her hesitation before she would agree to the procedure. But once trust was established, they gained her compliance.
“She was deathly afraid of any surgery, but after a year, she got the procedure,” Afshar says. “She stayed out of the hospital for eight months after surgery.” The patient’s cost of care decreased from $600,000 per year to $200,000 per year, he adds.
Physicians are skilled in managing patients’ disease processes, but to make a real difference to the most difficult patients in a health system, they need to do more than what they were trained to do.
“Just look at their disease process. That’s where integration of case management with the primary care provider team becomes critical to success in managing these patients — these highest utilizers and highest-cost patients in our healthcare system,” Afshar explains. “It was gratifying knowing that I could — with a little effort — make a huge impact on patients’ health and social needs.”
As any case manager knows, preventing readmissions and ED visits by the most at-risk patients is an enormous challenge. It requires addressing all the social determinants of health needs they may have, as well as finding creative and affordable solutions.
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