Kasey Kure, 33, used to visit Community Regional Medical Center’s emergency department about once a week because of seizures and other medical problems. He lived occasionally on friends’ couches, but mostly on the street or in a shelter and he didn’t have a regular doctor or money to pay for medication – until he met Xochitl Valenzuela, an outreach specialist with the hospital’s Community Connections program.

Now he has an apartment, a primary care doctor at Community Regional’s clinic, a church support group, he’s reconnected with family and he’s got a lead on a maintenance job. But best of all it’s been months since he’s had to go to the hospital. “If it wasn’t for Xochi, I don’t know where I’d be,” says Kure.
 

Community Connections' staff of 3.5 connects frequent emergency room visitors like Kure to resources to help get them off the street and to help them stabilize and manage their medical problems. In the first 20 months, Community Connections reduced emergency room visits by 52% and reduced the days those clients had to spend in the hospital by 77%.
 

The program is being expanded thanks to help from Humana Foundation which made a gift of $200,000 to add a nurse practioner and physician services. The clinical staff will help provide transitional care after discharge until patients can be linked to medical specialists and primary care out in the community. When the program first started in July 2009, the staff pulled a list of all the patients who had been to the hospital more than nine times in the previous year. There were 600 people on the list, said Caine Christensen, project manager for Community Connections. They reached out to those with the most visits first.
 

“One guy didn’t trust us so we kept meeting him at the library. One day I brought him fried chicken to eat and he finally said, ‘Yes I do need help.’” Christensen says. “This is real 70s social work. It’s going out to the streets.”
 

Community Connections' outreach specialists and social workers spend their days on the phone or combing homeless shelters, street corners and alleys looking to reconnect with patients. They celebrate little wins: when someone makes it to a follow up visit with a specialist on time, or shows up at the Social Security office, or buys a weekly pill organizer and uses it for their many medications. “Our job is to grab people by the hand and pull them along until they can walk beside us and then walk ahead by themselves,” Christensen describes the work.”When our clients get discharged from the hospital with a piece of paper and instructions, they aren’t going to follow up. Then they’ll be back. We’re working to make sure that doesn’t happen.”
 

Outreach specialist Marlene Rodriguez says the work is challenging but worth it. “This is so much more rewarding going out into the community and meeting our clients where they are.”

Rodriguez shrugs when friends ask if she isn’t worried hanging out where Fresno’s homeless congregate. “I feel safer out here than going to the store at night alone,” she insists. “People here know we’re from the hospital and we’re here to help.”

Once she gains a patient’s trust and finds out their challenges with housing, addictions, mental health, chronic medical conditions and/or coordinating their maintenance medications, Rodriguez gets on the phone to find a support network. Connecting patients to resources often means filling out mountains of paperwork, waiting on hold for government agencies to answer the phone, and going with clients for their initial meeting at social service agencies or with a landlord.
 

Mark Cowardin is one of Rodriguez’ success stories. In the two years before he met her, Cowardin had been to the emergency room 40 times, much of it stemming from unmanaged high blood pressure, heart problems and injuries suffered after he was mugged leaving his Reno casino job. A broken back left him unable to work and eventually he became homeless. Now his health is stable and he lives in a subsidized apartment. When Rodriguez visited recently, Cowardin showed off the furniture he had scavenged for his apartment and how he had organized his kitchen.  “I feel like I’m in a Hilton in Beverly Hills now,” he said. And when he heard about the Humana gift that will keep the Community Connections Program going Cowardin said, “Thanks Humana! Can we bake them a cake to say thanks?”
 

Erin Kennedy reported this story. She can be reached at MedWatchToday@CommunityMedical.org.