By JULIE MINDA
About six years ago, when Cathie Bowen was at Lima, Ohio's St. Rita's Medical Center for one of her numerous emergency department visits, hospital associate Susan Hawk approached her to gauge her interest in meeting informally and on an ongoing basis with a small group of local health and social service providers. This group, Hawk said, could help Bowen address the severe depression that was driving her to the hospital multiple times every month.
"I was pretty scared" to take Hawk up on the offer — it was such an unfamiliar activity, said Bowen, "but I knew something needed to change." And so, Bowen said yes.
Jeremy and Cathie Bowen
For several years prior to that 2012 meeting, Bowen had been wrestling with continually worsening depression. She was having difficulty eating, sleeping and taking care of herself. In the year prior to accepting Hawk's offer, Bowen had accrued 240 total inpatient days at eight hospitals — each stay triggered by an emergency department visit related to her severe depression.
Recalling that time, her husband Jeremy Bowen said, "When you're in the hospital 200-plus days a year, you don't have a family life. It's a hardship going through that." The couple, now in their early 40s, has a 21-year-old son.
The team that met with Cathie Bowen in private monthly sessions included Hawk, who is connected with the hospital's behavioral health unit, as well as a psychiatrist, therapist and nurse. Teams like this one intervene to provide practical assistance to several dozen patients each year.
With the team's support, Bowen sought and received intensive individual and group counseling and other social service support. Over the last few years, this has helped her to process self-esteem, anger and depression concerns and build coping skills. As a result, she reduced her emergency department visits to just several times a year.
Jeremy Bowen said of his wife's progress, "It's phenomenal. It took a lot of hard work" for her to improve her condition, including withstanding the emotional challenge of completing difficult mental health therapy.
Overutilization
Hawk is chief of clinical integration of behavioral health for Cincinnati-based Mercy Health, and director of clinical operations for behavioral health at Mercy's St. Rita's.
Hawk was working in St. Rita's emergency department in 2010 when she and other hospital leaders began to explore how best to address a persistent challenge: "We recognized the same patients kept coming back. … And most of these high-users suffered from significant psychological issues and experienced fragmented care. Many didn't do well in the traditional mainstream medical system — they didn't go to follow-up appointments … though most had significant comorbidities."
The thought group came up with the idea of providing extra support for patients who visited the emergency department at St. Rita's and other local hospitals six or more times in a month. Patients who accept the help meet regularly — usually once a month or more initially — with several health and social service agency representatives. The group aims to address the root causes of the patients' visits. Hawk said the concept is: "Let's identify the concerns, have the conversation and link people into resources. It's having the dialogue — that's (a process) we hadn't had in the past."
The heart of the matter
When a patient agrees to take part in the process, Hawk conducts an informal intake interview to learn what concerns are behind the patient's frequent ER visits. She's built relationships with nearly two dozen Lima-area health and social service agencies — including governmental, nonprofit and for-profit organizations. When assembling the team, Hawk contacts the representatives of the several organizations most aligned with the patient's needs. The team composition can change as the patient's needs change.
The patient chooses where and when to meet with the intervention team. Family members and loved ones can participate if the patient wants — the intervention team encourages family involvement. The patient receives a $5 gift card as a small incentive to keep the appointment.
Hawk said the patient guides the conversation in these meetings. "We don't put (the patient) on the spot, there's no pointing fingers, we just talk about their concerns and what might help," said Hawk.
She said, "It's all based on establishing a trusting relationship. The relationship we develop is the biggest tool we can provide in their recovery."
Client Ashley Torres, in foreground at right, takes part in a patient intervention team meeting with, from left, Susan Hawk, Whitney Ratliffe, Sarah Burke and, at far right, Theresa Zimmerman. Hawk represents Mercy Health's St. Rita's Medical Center; Ratliffe is a case manager with Coleman Professional Services; Burke is a support services associate with the Allen County Board of Developmental Disabilities; and Zimmerman is Torres' mother.
Gaining stability
Hawk said she currently has more than 30 patients meeting with intervention teams. Most of the patients are white; about 60 percent are women. The vast majority have mental health concerns and comorbidities. Substance abuse is a concern for many of the patients. Most are unemployed. Few have stable housing or transportation.
During the intervention team sessions, Hawk said, the providers at the table use motivational interviewing to tease out what might be the best approach for the team to take with each patient. Members of the group can teach a patient practical skills, such as how to sign up for insurance, how to access mental health services and how to negotiate the bus routes to access those services.
Sarah Burke is a service and support associate for the Allen County Board of Developmental Disabilities in Ohio; and Marie Langhals is a nurse navigator with Coleman Professional Services, a mental health services provider in the state. They are among the dozens of representatives recruited by Hawk for the patient support teams.
Langhals said, "It's neat when we come to the table and the light bulb comes on for everyone," and everyone realizes which solutions will work best for that patient. Without us coming together, we may never have seen what that patient really needed — they may not have known."
New routines
Hawk, Burke and Langhals said much of what they do is to help patients build up their knowledge of how to get help and to break off ineffective patterns — like seeking episodic care at the emergency department, when a primary care or urgent care visit would be more appropriate, or when an ongoing therapeutic relationship would yield the best outcome.
Many patients have achieved mental health stability, sought help for substance abuse disorders, gained increased control of chronic health issues, mended broken family relationships, gained stable employment and achieved housing stability. It can take a year for the patient to reach this sought-after equilibrium. As progress is made, the patient meets with the team less frequently. Team members remain accessible.
Hawk said that about 80 percent of patients stay with the process until they reach their goals. Those who stay reduce their emergency department use by an average of 50 percent after six months in the program.
Bowen, one of the program's success stories, is an advocate of the process. "I think I've improved quite a bit. It's made my family life better and I have a better relationship with my husband and son."
Husband Jeremy Bowen said, "Every hospital needs to have some type of program like this one."
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