As a University of Minnesota nursing student, I’ve worked with a diverse range of patients. The most memorable patient I have encountered was at a Cub Foods parking lot.
“You all don’t happen to have any extra cash, do you?” asked a middle-aged man in an old beat-up car from the ’90s.
I said, “Sorry, no” and walked briskly past him. It was a Sunday, get-your-homework-done day, so I was set on quick grocery shopping. However my friend, talkative as always, asked him, “What’s up?”
“Well, I need some money to buy some food. I just got out of the emergency department and I’m starving.”
Curiosity took over as I snaked back to hear more, which turned out to be a 15-minute conversation.
His name was “Barry.” At 43, he had several chronic conditions, including diabetes. He’d been in and out of hospital emergency rooms several times over the past few months because of financial difficulties and emotional problems. His health problems spiraled out of control after the death of his mother. His depression and neglect of his health fed into a vicious cycle of ER visits.
“Nobody told me how bad it was gonna get.”
‘High utilizers’ account for 21% of U.S. health spending
Stories like Barry’s are not as uncommon as one may think. Many people fall through the cracks of fragmented health care. They are termed high utilizers, patients who visit the hospital four times or more in a six-month period. Although they make up only 1 percent of the patient population, they account for 21 percent of U.S. health spending because of frequent ER visits instead of clinic visits, and tertiary care over preventive care. Better care for high utilizers is necessary to progress toward health care’s triple aim of healthier populations, higher quality of care and lower per-capita costs, thereby addressing moral and fiscal imperatives.
Minnesota has been a leader in more responsible health-care spending. In 2010, Minnesota moved from General Assistance Medical Care (GAMC) to a coordinated-care delivery system (CCDS) that made hospitals financially accountable for their care. CCDS concentrated on intensive primary care, inter-professional collaboration, and coordinated care. From 2010 to 2011, Hennepin County experienced a 38 percent drop in emergency-room visits and a 42 percent drop in repeat hospitalizations among those receiving such coordinated care.
While this is excellent progress, it is not enough.
This is where the Hot Spotters come in. Hot Spotting began in New Jersey over a decade ago by Dr. Jeffrey Brenner through recognition of the tremendous need of intensive primary care. Professional interdisciplinary teams worked with high utilizers to address inadequate medical care and high health-care costs. University of Minnesota students have started a Hot Spotters project with the hospital on the university’s East Bank campus in Minneapolis.
Mental illnesses prevalent
One of the most prevalent characteristic of high utilizers is mental illness, defined as a wide range of conditions that affect mood, thinking and behavior. Mental illnesses include but are not limited to depression, anxiety disorders and eating disorders. They are serious but often go undiagnosed and untreated.
Mental illnesses cost the nation $193 billion annually in lost earnings in 2008, according to the National Institute of Mental Health. Since mental illness has high societal costs, and because it is so common among high utilizers, making it a higher priority is necessary.
Policymakers should support mental health clinicians by creating an incentive program to better coordinate mental health services and primary preventive care. This will follow Medicare’s move last month of paying primary care doctors a monthly fee to provide holistic care for seniors.
Interdisciplinary collaborated care will better integrate the delivery of comprehensive services for individuals with mental health conditions and promote holistic health. Loan forgiveness to educate health care professionals to work in this needed area should be passed by the Legislature and signed into law by the governor this year. This must be paired with better reimbursement from public and private payers so mental health can be better managed and to reduce high utilization of more expensive care.
If Barry had received the comprehensive care he needed — through access to state- and community-funded social services and home visits, especially in regard to his chronic depression — his emergency room visits may well have decreased dramatically, benefiting everyone.
Hannah Chau is a nursing student at the University of Minnesota.
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