A barefoot Joyce Jones, 30, creeps like an old woman into the living room of her grandmother’s apartment, settles into an easy chair and talks to the person trying to keep her out of the hospital.
“I was in the ER last night,” Jones says weakly. “Had nausea. Abdominal pain.”
That’s not what Becky Wilkinson wants to hear, but Jones is making progress. Since Wilkinson stepped in two months ago, Jones has been admitted to the hospital once and in the emergency room five times. Last year, Jones was dragged into the ER 95 times and had 16 hospital stays.
Total cost: Just under $250,000.
Because Jones is on the Oregon Health Plan, federal and state government pays through Medicaid, a program for those with little or no income.
Wilkinson works for CareOregon, a Portland managed care organization for Oregon Health Plan patients. She’s among four outreach workers on its Community Care Team, a pilot project launched five months ago. The team focuses on the 25 percent of CareOregon adult patients who account for 83 percent of the spending last year — $311 million.
With primary care doctors, Wilkinson designs treatment plans for such patients to improve their health, reduce hospital stays and save money.
Oregon’s health care reform plan, now up for review in the Legislature, proposes to do the same. Outreach workers like Wilkinson will play a key role in the plan that is to unfold this summer with teams of doctors, nurses, dentists, therapists and other providers in what’s called Coordinated Care Organizations.
Like CareOregon, teams will target the costliest Medicaid patients to reduce hospital visits. If it works, the plan will save hundreds of millions of dollars, and people will have better care.
Wilkinson, a 39-year-old single mom of three, works out of Legacy Emanuel Medical Center in North Portland. The hospital supports her work to reduce inappropriate and unnecessary hospital visits, says Dr. Lori Morgan, chief administrative officer.
Wilkinson helps clients keep doctor appointments, eat better and organize their pills and lives. She gives them bus tickets, takes them food, reminds them to take prescriptions and keeps in touch through a daylong stream of texts, emails, calls.
She helped Jones find a state-subsidized apartment.
Jones grew up in Portland and has known she’s diabetic since age 11, but serious health problems emerged five years ago. Since then she’s endured a loss of most of her sight, high blood pressure, kidney failure requiring dialysis three times a week and nerve damage to her legs. Like many people Wilkinson works with, she also suffers from anxiety and depression.
Jones was sick of being sick and on the brink of giving up when Wilkinson showed up the day before Thanksgiving.
The outreach worker set up regular visits with a doctor and behavioral therapist, and made sure Jones took her insulin and drugs and showed up for dialysis. Those interventions have cut Jones’ ER and hospital visits in half.
“She is a big help,” Jones says. “She knows resources I don’t.”
Wilkinson worked for a year ending June 2011 in Bend on a similar project to divert Medicaid patients from emergency rooms. A group of private and public health care providers called the Central Oregon Health Council identified 144 Medicaid adult patients as high users of the emergency room, the highest being 56 visits.
About 65 patients enrolled with a community outreach worker and in a medical home that included a doctor and behavioral therapist. That alone cut emergency room visits in half and average costs per patient by 62 percent. Total saved: about $726,000.
Wilkinson returns from a five-day vacation on a Monday morning in January and learns several clients are back in the hospital. One is Brittany Kowalski, 21, a woman who for years bounced around foster homes before landing back with her mom in a Portland motel room.
Wilkinson first met Kowalski in an ER two days after Christmas and enrolled her as a client. By then, Kowalski had been with CareOregon only a month, but in the emergency room five times. Wilkinson has not pushed her to reveal more than she wants about her life.
“Who knows what she’s been through,” says Wilkinson, as she heads to the Adventist Medical Center in Southeast Portland.
There she finds the thin, pale Kowalski, who looks young enough to be in middle school, dressed in silky shorts, a T-shirt and sweater lying on a couch in the emergency room. She lies on her side in a fetal position with her knees pulled up slightly and her hands over her mouth. A nurse says her heart was racing at more than 120 beats per minute so doctors are watching Kowalski.
Wilkinson engages in small talk about her dog, her trip to California. She stretches a wide-striped sock up over her black pants to show Kowalski the socks she wore during her roller derby days.
Kowalski relaxes and sits up. She says she was admitted to the hospital two days over the weekend. This is the first trip to emergency since Wilkinson started helping her.
A nurse comes by and checks the woman’s pulse.
“That’s much better,” the nurse says.
“My hands are still tingly,” says Kowalski. “My face is really tingly.”
Wilkinson finds her a sandwich and soda, and offers her a bus ticket to get home. Kowalski says she’s light headed. She thinks she might pass out on a bus, so she’s waiting for a ride from an aunt.
Wilkinson will text Kowalski through the day, as she does every day. She’s helped her with transportation and even taken her food. Her goal is to help Kowalski find enough self-sufficiency to control her anxieties and see a doctor regularly so she doesn’t keep hitting the ER.
Wilkinson’s “been very helpful,” says the soft-spoken Kowalski. “I don’t even look at her as a worker. I look at her as a friend.”
While Wilkinson builds trust with her clients, she also keeps her distance. They don’t know, for example, where she lives.
“I do lots of hand holding at first,” she says. “After six months, they won’t be so needy.”
At a round kitchen table in the North Portland home of M. D. Jones, Wilkinson sorts pills from 14 plastic vials into an ice-tray like plastic grid with four chambers for each day of the week.
“Did you test your blood sugar today?” she asks
“No,” says Jones, 52, no relationship to Joyce Jones. He has diabetes and limited vision.
“Did you take your insulin?”
Wilkinson shakes her head with a smile.
“Can you take a measure of your blood sugar and weigh yourself, too?” she asks.
He does. His blood sugar is high; he weighs in at 192.
She asks him to take some insulin. He fills a needle and goes by the window for better light and injects a shot in his upper left hip.
Jones also has congestive heart failure after two heart attacks a year ago in Mississippi. Since he joined CareOregon three months ago, he’s been in the hospital nine times and the ER twice.
The hospital’s become a second home, he says.
Wilkinson discovered that was in part because with failing eyes, he couldn’t read directions on his prescriptions, a problem she immediately fixed with the plastic pill grid. Jones has not been to the hospital since he met Wilkinson Jan. 4.
He lives with other retired adults in the drafty old house and is reluctant to put his insulin in their common refrigerator for fear one of the other residents will take it. Wilkinson says she can get a portable refrigerator for his room. She’s looking for a place he can live on his own.
“The Lord sent you to me,” he says.
Wilkinson found most of her 10 clients in the ER at Emanuel. After five months, doctors are getting to know her, she’s drawing more referrals and has several more potential clients on her radar. Over time, some clients will develop resources and routines, get healthier and no longer need her.
She sits with her boyfriend of more than 30 years, Onia Bates, 62, and their daughter, Ashley Bates, mother of their curly-haired 4-year-old grandchild. As they wait, Bates expresses his frustration with uncertainty over what is causing Pankey to seem so weak and in pain. Doctors alluded to pneumonia and liver problems before she was recently released from the hospital, but drew no conclusions, he says.
“They are not explaining it,” he says. “At least tell us something.”
“I’m a bridge between you guys and the care system,” Wilkinson says.
Today they’ll need a bridge.
They wait an hour and then are ushered into an examining room where they wait another 30 minutes. Finally, a resident doctor who Pankey has never seen arrives. Pankey, slouched in a big chair, tells her she’s in pain.
“I want to go back to the hospital and find out what is wrong with me.”
“Tell me what you understand about why you are here,” the young doctor says.
“They don’t seem to be able to tell what is wrong,” Pankey says.
The doctor asks if she is there for help with pain.
“Yes, something or put me back in the hospital,” she says. “It is a dull pain, just naggin…I can’t eat. I can’t sleep.”
“I don’t think pain medicine is a good solution,” the doctor says. She prescribes a colonoscopy and an electrocardiogram. No pain killers.
She brings in a woman to describe to Pankey other ways to manage pain – support groups, diet changes, warm pads, massage.
“They are not going to work for me,” Pankey says. “I sleep one hour a night. Sometimes, I don’t go to sleep for two days.”
Pankey is so angry she refuses to even talk to the doctor. She turns, instead, to Wilkinson.
“I’m just going to go home and get me a whole bottle of Excedrin PM.”
After three hours in the clinic, she leaves, enraged, exhausted and in pain. She vows never to come back.
Six days later, Pankey passes out at home, is rushed by ambulance to Emanuel, where she is admitted because of irregular heart beat related to congestive heart failure. She’s released three days later and ready to give the North Portland clinic another try.
“She is feeling better,” says Wilkinson. “Today, we’re going to the doctor.”