Multi-faceted approach to healthcare yields results
Dr. Elmore Rigamer, a psychiatrist who serves as the medical director of Catholic Charities Archdiocese of New Orleans, loves to go where the data says he should go, but he also listens carefully to the stories people tell.
After the BP oil rig explosion in 2010 discharged 4.9 million barrels of crude into the Gulf of Mexico, devastating the south Louisiana fishing, shrimping and oystering economies, Catholic Charities used BP money to send teams of case managers to assess the human and emotional damages in the most-affected communities.
No one needed to be a rocket scientist to see the problem behind the problem, Rigamer said.
“We were being asked to deal with the emotional fallout from the spill, but after two or three months of seeing people in Port Sulphur and Venice and all the places down in St. Bernard, it became clear that I couldn’t, as a psychiatrist, be treating people for depression without addressing all the other physical health problems.”
State residents at risk
Even without a major disaster exacerbating the problem, Louisiana is one the worst states in the nation in terms of the high percentage of people suffering from multiple chronic diseases and the low percentage of those who have health insurance and access to regular health care, Rigamer said.
Louisiana residents are among the Americans most at risk for diabetes, high blood pressure and cardiopulmonary issues.
“It was just a ridiculous position for a psychiatrist to be in – offering Prozac to a person who didn’t have insulin for his diabetes,” Rigamer said.
That’s when BP gave Catholic Charities permission to expand the scope of its original case management project to send affected individuals to health clinics, where they could be seen by a primary care doctor. Catholic Charities used two “patient navigators” to help individuals get the health care they needed.
The ‘Hot Spotters’
When the new outreach began, Rigamer learned more about a program called the Hot Spotters, started 10 years ago by Dr. Jeff Brenner in Camden, New Jersey. Brenner’s idea was to canvass emergency rooms to find out exactly why people were coming there. The individuals were tracked by zip code.
“A lot of people live in highrises, so he went into the community and started working with people to figure out what was causing them to go to the emergency room or the hospital,” Rigamer said. “He figured out if they got primary care, it would reduce the inappropriate use of the health care system and improve their care. It’s not rocket science that if you treat diabetes in a primary care clinic with education, it’s better than treating it in the emergency room.”
Using the New Jersey model as a guide, Catholic Charities received a three-year, $1 million grant in 2012 from the New Orleans Charitable Health Fund to establish Health Guardians, which provides healthcare navigators for persons with serious physical and mental illnesses. Rigamer worked with Dr. Joseph Kanter, medical director of the New Orleans Health Department and Health Care for the Homeless Clinic, and Dr. Jennifer Avegno, an emergency room specialist.
“They really jumped on this idea, and we couldn’t have made it without them,” Rigamer said. “They kept seeing these people every day, and they referred them to us.”
The navigators started by asking a simple question: Why did a person come to the emergency room? The persons chosen to participate in Health Guardians were those who seemed to be chronic overusers of the ER system – those who had made three or more emergency room visits or who had been hospitalized twice for the same disease within the previous six months.
The primary reason for emergency room overuse was lack of access to primary health care, Rigamer said. The majority of persons coming frequently to the ER are uninsured.
Other problems uncovered were lack of transportation to attend primary care appointments, not taking medication as prescribed, the high cost of prescriptions and mental health issues. The transportation issues could be handled with bus or taxi arrangements, and taking medication properly is a function of educating patients on their conditions, Rigamer said.
The navigators set up personalized care plans in consultation with the patients so that they could understand and buy into staying on track. They helped enroll patients in Medicaid and accompanied them on medical appointments at neighborhood clinics to make sure the patient and the doctor understood their problems. The navigators also followed up frequently with each patient, even doing home visits.
The results were extremely encouraging, Rigamer said. A study of 55 Health Guardians patients showed that nearly 73 percent had fewer ER and hospital visits in the six months after starting the program. As a group, they totaled 116 fewer ER visits and 25 fewer hospital admissions, with cost savings to the system of $16,721 per patient – a total of $919,875.
While Health Guardians, which is directed by Seema Dave, started in partnership with University Hospital, it is now partnering with 10 community health clinics in the Greater New Orleans area.
“We want to remove any barrier to health care in our community, whether that be housing or employment issues or managing physical and mental illness,” Rigamer said. “A lot of Catholic Charities clients have a low sense of agency – they don’t feel they can make things happen. Instead, ‘things’ happen to them. We want to change that. We want them to go to their doctor and ask the questions that will help them manage their treatment, not just take a pill.”
Rigamer hopes Health Guardians will continue beyond July 2015 when the initial grant period ends. “We’re approaching foundations and other benefactors,” Rigamer said. “We have a lot more clinics in the community than we did before Katrina. Before Katrina, a lot of the care was emergency room care. This program makes sense. We not only improve care – we save the health care system money.”