Can helping high-risk patients with basic needs reduce costly care in rural areas?


JUDY WOODRUFF: Fifty percent of health care spending in the U.S. can be traced to just 5 percent of the population. Those are the sickest and often poorest Americans who spend much of their time cycling in and out of costly emergency care.

While congressional leaders square off toward a vote next week on the future of the health care law, there are pilot projects on the ground that are focused on how to improve treating this group of patients and also to save money. That's even the case in remote areas.

Special correspondent Jackie Judd has our report from Kalispell, Montana.

JACKIE JUDD: Not so long ago, Sheran Greene and her beloved dog were living in a car in downtown Kalispell, Montana, and routinely heading to the local emergency room because of chronic lung disease and the need for an electrical outlet.

SHERAN GREENE, Patient, Kalispell Regional Healthcare: I was there like clockwork every day, sometimes being treated, sometimes having to charge up my oxygen machine, which I used, because I had no electricity. Sometimes just getting out of the cold.

JACKIE JUDD: It is this cycle of patients going in and out of the hospital, at great cost, with not much benefit, that the group around this table is trying to break.

MEETING LEADER: How can we avoid some of these emergency room visits that really are not necessary?

JACKIE JUDD: A pilot program funded by the federal government and a foundation began late last year in Kalispell, Billings and Helena.

JANE EMMERT, Community Health Worker: How are you?


JACKIE JUDD: Health care players already in the community now team up in a very deliberate way to identify high-needs patients and to go well beyond the traditional bounds of medical care.

JANE EMMERT: Do you think you can find housing that'll take your Section 8 voucher?


JACKIE JUDD: Lara Shadwick directs the Montana program.

LARA SHADWICK: Some of the themes really rest on social determinants of health: lack of transportation, housing insecurity, food insecurity, economics, finances. Those are really some of the drivers that are the commonalities for these patients.

JACKIE JUDD: The Kalispell care team runs lean. There are community health workers, like Jane Emmert, who are trained to manage non-medical issues. And the head of the team, registered nurse Lesly Starling.

Together, they aim to reset the paths these patients are on.

LESLY STARLING, ReSource Nurse, Kalispell Regional Healthcare: They're so sick. They have gotten so used to the way that they live. I do feel like patients get very used to their environment, and they get very used to their choices. They get very used to their lifestyle. And it's not — it's almost like they build up an immunity to what their life looks like.

JACKIE JUDD: David Dixon was once a member of an emergency medical team and a fishing and hunting guide. Since a disabling motorcycle accident, he struggles with chronic pain and nausea, overuse of medications and episodes of depression and anxiety.

In a 14-month period, Dixon went to the E.R. 42 times.

DAVID DIXON, Patient, Kalispell Regional Healthcare: I just want to have a better life. I want to be able to wake up in the morning and have a halfway decent day. I would like to be able to make plans for tomorrow morning.

JACKIE JUDD: In just a few weeks, the team has helped Dixon to reconnect with a pain specialist and link him up to a pharmacist to sort out the many medications he is on.

RITA BARTLETT, Pharmacist: Are you taking that one also pretty regularly?

DAVID DIXON: There's so many medicines I'm taking, that I don't know which ones are really helping and which ones aren't at this point.

JACKIE JUDD: Dixon, like so many high-needs patients, has mental health issues. Specialists in Kalispell are in short supply, so Starling typically gets advice from an expert some distance away about how best to work with patients.

PATRICK VAN WYK, Psychologist: It sounds like you have been using a lot of those, some of the motivational interviewing skills that we have been talking about. Finding what kind of barriers there are for him. Finding what his goals are.

JACKIE JUDD: Sometimes, a patient's need is as basic as a roof over one's head.

The team found Sheran Greene an affordable apartment, which is no easy task in Kalispell. Starling acts as a liaison to Greene's primary care doctor. And other community workers literally deliver Greene to Dr. Jonathan Anderson's door.

DR. JONATHAN ANDERSON, Greene's Physician: Good.

SHERAN GREENE: So, do I have a heart?

DR. JONATHAN ANDERSON, Big Sky Family Medicine: It's still beating.

She's allowing people into her life, is what she's doing. Before, it was basically the E.R. and the hospital, and then she'd come in for follow-up visits here, and then she'd bounce around and come back. Now she's allowing people from the community to come in, and allow them to help. Either help her move things, allow them to kind of check in on her and make sure she's doing all right.

JACKIE JUDD: When Greene was homeless, in one six-month period, her Medicare charges were $100,000. Since November, hospital charges are less than $6,000.

By the time this pilot program ends, the hope is over $2 million will be saved. Programs like these first came to urban areas. Rolling one out in a vast rural state like Montana is a very different kind of experiment, with very unique challenges … starting with simple geography.

JANE EMMERT, Director, ASSIST: Sometimes, we're going on mountainous roads that are icy and treacherous. Sometimes, they're narrow dirt roads that you aren't sure that you want to go down.

JACKIE JUDD: To get to a patient can be a 60-mile round trip. So Emmert frequently heads out on her own to their homes, as she did on this day, to visit 25-year-old Mackenzie Kramer, who is slowly recovering from major surgery.

JANE EMMERT: So, if you try to do any of this, and it's tough for you, just know what we'd be glad to help you fill it out.

JACKIE JUDD: Emmert is there to help him manage the paperwork for disability, and to put him in touch with Starling, who can check up on many more patients if she stays behind in her Kalispell office.

LESLY STARLING: How has the pain been?

MACKENZIE KRAMER: It's been manageable. It's getting better, I think.

JACKIE JUDD: The team also gently pushes Kramer to think about his future once his health stabilizes.

JANE EMMERT: He's got to have something to look forward to. So that's why we're looking into possibilities with college, or a job, that he could reclaim the life of a 25-year-old again.

JANE EMMERT: Part of the goal is to help you connect to things you might not have already.

DAVID DIXON: Somebody that knows where to go, how to do it.

JACKIE JUDD: You have a whole team of people, right?

DAVID DIXON: Well, I have a whole team of people.

JACKIE JUDD: Progress with these patients can come in fits and starts. Less than 24 hours after a home visit filled with encouragement to manage his illnesses differently, David Dixon takes himself back to the E.R.

JACKIE JUDD: What happened?

DAVID DIXON: I woke up nauseous and vomiting, and took my medicines and couldn't keep my medicines down, so I went for a trip to the hospital again.

JACKIE JUDD: Dixon's team wasn't surprised that he went to the hospital, his visit a reminder of how fragile these patients are and how much work it takes to break the cycle.

DAVID DIXON: It's taken years to get me where I am. They're starting to understand it. They're starting to get programs together that fill in the gaps in the medical profession, where I had problems before.

They don't know everything. It's not a magic wand, but at least they're trying.

JACKIE JUDD: The pilot program has another year to prove these intensive interventions can succeed, and, if so, whether there is the funding and the will to make them a new standard of care for the most challenging people to treat.

For the NewsHour, this is Jackie Judd in Kalispell, Montana.

JUDY WOODRUFF: Two quick notes about Jackie's story.

It is not yet clear whether the moves by the president and Republicans to replace the Affordable Care Act will affect the funding of programs like this one.

And, for the record, the Robert Wood Johnson Foundation, which helps to fund the Kalispell pilot program, is also a funder of the NewsHour.

Recently in Health