Deborah Knowlin slowly limps to her kitchen table, favoring her left knee because her right one, she says, gives out frequently.
Sitting down at the table, Knowlin snaps open a day-of-the-week pill box and empties Friday's contents into her right hand: a half-dozen pills. Knowlin, 54, used to take 13 medications a day to manage her long list of ailments, including Type 2 diabetes, back pain from four slipped discs, liver cirrhosis, pancreatitis, high blood pressure and depression.
Her blood sugar dipped and soared when she first started feeling the effects of diabetes a couple of years ago. She would feel dizzy and lightheaded. Then she would go to the emergency department at Saint Francis Hospital and Medical Center in Hartford to have her condition stabilized.
"I'd be trembling," Knowlin said.
Two years later, with the assistance of a case manager through a local nonprofit, Knowlin has stabilized her diabetes and is on fewer medications. She was among a dozen people in a pilot program by Saint Francis and a non-profit called Community Solutions to reduce emergency-department visits.
The small program is trying to address a persistent problem that may hold the key to holding down runaway health care costs, not just here but across the country: how to keep people, especially in poorer neighborhoods, from using emergency rooms like doctors' offices. At issue, however, is a much broader challenge of the relationship between poverty and poor health.
Knowlin is like a lot of people in Hartford's North End who go to the emergency room for all types of medical care. It's a quick remedy even if the ailments could be treated in an urgent-care facility or by regular visits with a primary care physician and follow-through on medical advice.
People who have Medicaid coverage use hospital emergency-department care at almost twice the rate of people with private health insurance, according to a January report by the federal Centers for Medicare & Medicaid Services, or CMS. It's not as though there is widespread inappropriate use of emergency services among Medicaid patients, who are typically in poorer health than people with private health insurance, but rather that they struggle with a lack of access to appropriate medical settings, according to CMS.
Treatment at the emergency department is expensive — to taxpayers who pay for Husky health coverage, the state version of Medicaid for people with low incomes; and to hospitals that are reimbursed at lower rates by Medicaid than by either private insurers or Medicare, the government coverage for people 65 and older.
Also, emergency care is not the most efficient or best way to treat ongoing chronic conditions such as diabetes.
In the summer of 2011, as Saint Francis looked for a more efficient and coordinated way to treat patients, the hospital developed a registry of all visits to its emergency department with the goal of understanding patterns of use and reasons for those patterns. Hospital staff surveyed patients in the emergency department. They pored over data.
"As we did this data gathering, we realized this is less an issue of patients that could be going to their primary care doctor instead of going to the ED [emergency department], and more an issue of high utilizers, high utilization of the ED [emergency department]," said Gregory Makoul, chief innovation officer at Saint Francis Care, the hospital's parent company.
If someone goes to the emergency department one time in a year, rather than see a primary care physician, that's not as significant as a person who goes to emergency department 20 times a year, Makoul said. The hospital narrowed its focus to 54 people, each of whom was treated 18 times or more at the emergency department in 2012.
Saint Francis connected with Community Solutions, a non-profit group in Hartford's North End. The non-profit is working to improve the health, employment, quality of life and other conditions of people in "Northeast Hartford," which is a section of the North End.
"Their drive to really try to revitalize the Northeast neighborhood really coincided with this work," Makoul said. "So, we connected with them."
The hospital and the non-profit started small, narrowing the list of 54 people who frequent the emergency department to a pilot program of a dozen. Community Solutions assigned a case manager, Nadia Lugo, to reach out to patients — once the patients gave the hospital approval to do so.
The hospital had success in nine months. Emergency department visits by those dozen patients — including Knowlin — were reduced by more than 50 percent, according to Saint Francis. Lugo worked with people to get them to understand their circumstances and to help them get appropriate care.
In Knowlin's case, Lugo was a patient advocate. She helped to communicate Knowlin's medical concerns to a primary care doctor at a clinic in Asylum Hill and, aided by a visiting nurse, helped Knowlin follow through on her treatments.
One goal is more efficient treatment. It remains to be seen if cost savings from fewer emergency visits, and better coordinated care for people in poor health, will outweigh the time and money spent by nonprofits, philanthropic organizations and others to fix the problems. An exact accounting would be difficult — what is the value of aggregate health improvements over a long period?
Cigna Lends A Hand
Even with early success, there's a much larger challenge in the complicated socioeconomic circumstances that cascade down on people in the North End.
Evictions. Joblessness. Low, if any, income. Lack of consistent housing and availability of affordable, nutritious food. It all contributes to poor health for some people in the North End, according to a Community Health Needs Assessment by the Hartford Department of Health and Human Services.
It can be difficult for people to focus on health when they are worried about the basics of life, including safety. The North End and other parts of Hartford have higher rates of crime than the rest of Connecticut, which concerns city residents, according to Community Solutions and the city's Community Health Needs Assessment in 2012.
Knowlin struggled with the threat of eviction and financial instability. She said her physical conditions have kept her out of work since her last job in 2001, when she was on her feet at a delicatessen preparing and serving food.
"I mostly stay in bed a lot," Knowlin said.
She is on State Administered General Assistance. She copes with depression, and one of her five daughters has had serious mental health struggles. Lugo has helped Knowlin stay on her depression medication, Zoloft.
"It's not bad as it was. I'm not doing all that crying that I was, wanting to kill myself," Knowlin said.
Circumstances in the North End can seem hopeless to some, but Community Solutions and Saint Francis are optimistic about making progress. And they've been joined in the past year by the Cigna Foundation, which is planning to provide health coaching programs, data analysis, diabetes education and outreach strategies to address big health trends in the North End.
"If an employer group came to us, if all 10,800 people in this neighborhood worked for one company, Cigna would look at this group and we would perform some type of assessment … to understand more about this population," said David Figliuzzi, executive director of the Cigna Foundation, the philanthropic organization funded by Cigna Corp.
"We would query claims history in order to get a profile of what was happening with the group as a whole to understand the trends, the macro trends," Figliuzzi said. "And then we could use all of that data because we've got the ability to crunch big data and to look at populations and understand what the trends and drivers of health care utilization are, and the drivers of poor outcomes."
Cigna is working with the state to get Medicaid claims data on the North End — without identifying individual patients — in order to learn the trends.
A group of Cigna workers spent a weekday teaching high-school students in the neighborhood how to do a social media campaign to engage children in the neighborhood. Some Cigna employees took the "youth leaders" by van to the Cigna Innovation Lab at the University of Connecticut at Storrs.
This fall, Cigna is bringing a program called Blessings in a Backpack to the Frank T. Simpson-Waverly Elementary School in the North End to provide nutritious food over the weekend for students who need it.
"This, for us, is really our flagship or signature expression of social responsibility in the Hartford community, is this Northeast neighborhood," Figliuzzi said.
In terms of analyzing health trends in the neighborhood, some issues have been studied already, and the results published.
The North End is one of the poorest neighborhoods in the city and the state. Fifty-five percent of households in the 06120 zip code made $24,999 or less in annual income — and 29 percent made less than $10,000, according to U.S. Census Bureau statistics from 2008 to 2012. In the other zip code in the North End, 06112, 44 percent of households earn $24,999 or less in annual income, and 18 percent made less than $10,000 during the same time period.
Poverty is correlated with higher rates of chlamydia and gonorrhea, trauma-related hospitalizations, mental health emergency-department treatments, homicide, hepatitis C, diabetes, drug- and alcohol-induced deaths, infectious and parasitic diseases, according to a 2012 Community Health Needs Assessment by the city's Department of Health and Human Services.
Case In Point
Shacoya Parkman, 21, suffered constant menstrual cramps in 2012. She was living in Philadelphia at the time, working a commission-based job for an energy company, knocking on doors and trying to get people to switch electricity providers far away from where she grew up in Hartford's North End.
She self-medicated for cramps by taking acetaminophen, a generic form of Tylenol. One day she took so much it caused serious liver damage, Parkman said, and she was hospitalized for weeks in Philadelphia.
"So, I was stuck out in Philly for a month in the hospital," Parkman said.
After she was discharged, Parkman moved back to the North End. She went to the Saint Francis emergency department for stomach pains and pancreatitis. Parkman said she was given a pain killer, Dilaudid, which is an opioid.
"I ended up getting addicted to pain pills, and that was like a whole another thing I had to go through. It was crazy," Parkman said.
Some weeks, she went to the emergency department three times a week trying to get more Dilaudid.
Lugo said she reached out to Parkman shortly after Parkman withdrew from Dilaudid, which caused a three-day torment of nausea and anguish. Parkman is one of the dozen North End residents referred to Community Solutions by Saint Francis because she was a frequent patient at the hospital's emergency department.
Parkman has a 1-year-old daughter, Saroya, but the father is not involved in Parkman's daily life, she said. As a young mother, she is trying to figure out how to find a job, day care, and a consistent place to live.
On a weekday in early August, Parkman was temporarily living in Hartford's South End after hopping from her mother's two-bedroom apartment to another place with her father's daughter, then another still — but that place didn't have functioning water pipes, she said. The apartment in the South End was in a home owned by a family friend, but the home is in the process of foreclosure.
Lugo is working with Parkman to get an apartment — which requires proof of income, a job, and day care. The hope is that if she can live with her brothers for some time, their income will help get an apartment, and she can try to arrange her life from there: getting a job, day care and transportation. Community Solutions has been a big help, Parkman said.
"They're like the first people to tell me anything, any kind of job openings and applications," she said.
She still gets menstrual cramps, but Parkman deals with the pain.
"I get it every morning," she said. "It doesn't last as long as it used to. … I learned to manage it on my own."
Makoul, the innovation chief at Saint Francis, realizes that simply reducing visits to the emergency department doesn't fix the root causes of those visits.
"The focal point is utilization of the ED, but that's more a symptom of something else," Makoul said. "How can we address the fragmentation of medical care? How can we address, essentially, what for some people is the fragmentation of just life, everyday life?"
"A health care institution is probably not the perfect organization for doing some of that work on the social determinants, which is why it's so important to partner up with an organization like Community Solutions," Makoul said.
Community Solutions, formerly Common Ground, became involved in the North End in 2010 when it was gifted the 60,000-square-foot M. Swift & Sons factory. The former gold-leafing company closed in 2004. The Swift family considered demolishing the factory, but preservationists sought out Common Ground to take over management of the place.
The building is seen as a keystone property that could be used as a job-training site and a way to improve the nutrition and food sources of the neighborhood. As a start, there is a large garden on the property. A similar model is already functioning in the Frog Hollow neighborhood of Hartford: the Billings Forge Community Works, which runs a farmers' market, a teaching kitchen, a catering business, an arts studio, apartments, youth programs and a farm-to-table restaurant called Firebox.
"We absolutely see this as very simpatico with Billings Forge. The one difference might be that we are looking at the whole neighborhood system," said Rosanne Haggerty, president and CEO of Community Solutions.
The New York-based non-profit has been featured in the Harvard Business Review, The Wall Street Journal and "60 Minutes" and elsewhere for its work coordinating existing services to help homeless people. In Hartford, the goal is to use the Swift factory to improve health and employment, but in a way that pulls together existing resources for low-income people in the North End.
One idea is to create work for residents in the community as health navigators and coaches for chronically ill individuals who also live in the Northeast neighborhood, Haggerty said.
Community Solutions has started working with the state of Connecticut to figure out a partner that could employ local residents as health coaches, with the idea that there is the potential for cost savings to taxpayer-funded institutions such as Medicaid. Cigna's health coaches could train the local residents.
"That's a home run for everyone," she said. "People stay out of the institutional settings that are so costly, live better lives, more healthy lives, and work is created for people in the community who need it. That's just a window into one part of the strategy."Copyright © 2015, CT Now