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Program has reduced nonessential emergency department visits

By JULIE MINDA

In late December 2012, Donald Nielson was working toward sobriety at a Salvation Army rehabilitation facility in Orange County, Calif., and was poised to rebuild his life after five years living on the streets around Fullerton, Calif., when he sustained a debilitating heel injury.

He ended up in the emergency department at Fullerton's St. Jude Medical Center in January 2013 because of complications from the injury. Because he did not have anywhere to go upon discharge, clinicians referred him to St. Jude's full-time community care navigator for the homeless, Jessica Grimes.

Jessica Grimes, left, the community care navigator at St. Jude Medical Center in Fullerton, Calif., meets with patient Darnell Pope at a park in Brea, Calif.

"Since day one, she took care of me — she took over my care," said Nielson, 57. "She hooked me up with the resources I needed so I'd have a place to stay and money so I could get sober and back on my feet."

Now residing in a sober living facility in Anaheim, Calif., and completing physical therapy for the heel injury, Nielson reunited with a son and a grandson he'd lost touch with while on the streets. He attributes much of his success to Grimes' support. "Without St. Jude I don't know where I'd be now. It's unbelievable the care I've gotten — it blew me away."

Nielson said he was amazed that, between Grimes and the people Grimes connected him to, "there were so many who cared about someone who was nobody" to them.

Soul searching
Since she created the community care navigator program for the homeless beginning in August 2012, Grimes has been meeting St. Jude's homeless patients when they come into the emergency department to assess their situation and to identify ways she can assist them in getting medical care and wraparound services. She has built relationships with people who staff programs and services at the hospital and in the community with resources to help homeless individuals. She uses those connections to ease the way for homeless people seeking medical care, mental health care, basic provisions, housing, addiction help and more.

The navigator program has its roots in the 2011 beating death of a mentally ill homeless man at the hands of Fullerton police. Kelly Thomas' death was caught on a video surveillance system, and the video went viral. The death received national attention. "The city was ashamed," explained Barry Ross, vice president of healthy communities for St. Jude. He said Thomas' death "caused the entire community to do some soul searching."

To assess how it was handling the needs of its homeless patients, St. Jude pulled data on people who sought care in its emergency department and said they had no address. It learned that there were many homeless individuals who came to the emergency department multiple times — one man came 65 times in one year — and many for nonemergency needs related to substance abuse or mental illness, or a lack of food, clothing and shelter. St. Jude put Grimes, a hospital social worker known for her work with the homeless, in the ER in the new position of community care navigator, to develop relationships with — and advocate for — homeless patients and other highly vulnerable patients.

Early riser
Ross said "it takes a lot of time and energy to build the relationships."

Grimes' initial contact with her homeless clients generally occurs in the tight window when they are at St. Jude — once they leave, they likely will be hard to find, because many homeless people are reticent to disclose where they stay. Grimes is typically up around 4 a.m. so she can get to the hospital early to catch people who came in the night before. She introduces herself to homeless patients, works to gain the patients' trust, assesses their needs and tries to learn where she can find them in the community. In order to stay engaged with her clients after they leave the hospital.

Much of Grimes' day is consumed with working with her clients to help them secure medical follow-up, secure transportation to appointments, connect with sobriety programs or access housing programs.

"Every day is different," she said.

Moving the needle
The community care navigation program has an annual budget of about $120,000 that is covered by St. Jude community benefit funds. The program is still in pilot mode. The results are not yet in, but Ross said that there is early evidence that having a navigator significantly reduces unnecessary emergency department visits. This saves the hospital the money it would have spent on charity care for the patients, or that it would have lost by treating patients insured through a government payer when reimbursement does not cover costs. About 47 percent of the individuals Grimes worked with in fiscal year 2013 were insured through a government payer, be it Medicare, Medicaid or a county program; 41 percent were uninsured; and nearly 12 percent were commercially insured, usually through a parent or estranged spouse, or had another source of insurance.

At this time, the program's achievements can best be gleaned through the stories of homeless people helped, said Ross.

For instance, one homeless woman sustained an injury that prevented her from working and attending a sobriety program she was trying to complete. Grimes and agencies she works with helped the woman secure Social Security disability payments and to seek care for her medical issues. The woman is now sober and living independently, according to her case study in a St. Jude community care navigator report.

No place to go
Of the 369 homeless people who came to St. Jude's emergency department for treatment in fiscal year 2013, about 60 percent had mental health issues and about a quarter had substance abuse issues, according to the hospital.

Grimes said that while there are many programs available in Fullerton to assist the homeless, the programs can and do fill up. She tries to keep a running inventory of programs that have openings at any given time. Housing is a perpetual challenge because there are no permanent housing programs for the homeless in Fullerton. Grimes directs clients who qualify to transitional housing programs that may be able to lead them along a road to permanent housing.

Grimes works with her clients to establish goals and expectations, including complying with clinicians' instructions, adhering to the rules of a sobriety program and completing the forms necessary to access aid. But, there are many hurdles for homeless patients. For instance, Grimes said, diabetics living on the streets often have their needles taken away by police who suspect that the needles actually are being used for illegal drugs or who are wary of being poked with the needles. People taking prescriptions, when they're able to get them, don't always have the stability to remember to take medicine at the proper times, in the prescribed ways.

"Some say, 'I'm 65. I'm not going to stop drinking.' Or, 'I want to live on the waterway behind the hospital.' It's often three steps forward and two steps back" when assisting the chronically homeless, Grimes said.

"It's frustrating, but it's part of the relationship. Sometimes they aren't going to like me because I'm being firm, but I have to be consistent" in setting and maintaining boundaries.

"You keep trying and don't give up," Grimes said. "In social work, you don't give up."