One patient at MedStar Harbor Hospital in South Baltimore had uncontrolled asthma. Another had chronic skin infections related to an autoimmune condition. Their diseases were different but caused the same problem.

“They had a significant number of visits to the emergency room,” said Jenna Everett, a physician assistant in Harbor’s emergency department. “Getting resources for them was essential.”

Those resources came from an initiative Everett has been helping build in four MedStar hospitals since 2021 called the Multi-Visit Patient Program. It addresses underlying medical conditions, but also social and behavioral issues that can end with poor health for individuals and more pressure on already overloaded emergency departments. Data shows that it’s working: The program has reduced emergency visits by half among the patients it serves.

The concept isn’t new; officials said the program is modeled on a year-old effort in Boston and also reflects programs in other Maryland hospitals. MedStar now hopes to expand to more hospitals in its system and has begun talks with other health systems in Baltimore about cooperating on common goals to reduce use of emergency rooms.

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Hospitals are already partnered with community groups on a statewide pilot program providing housing and support services to help people stabilize their overall lives and health. There’s interest in other collaborations that address needs of patients who show up in hospitals or before they need to come, said Dr. Chuck Callahan, vice president of population health at the University of Maryland Medical Center.

Callahan said a possibility is expanding a program the center has with the Baltimore City Fire Department, sending paramedics and nurses to people’s homes when they call 911 to address concerns and avoid a hospital trip. They found just 5% still needed transport to a hospital, freeing ER space and the ambulances.

They also could resurrect a pilot program in which paramedics and nurses visit patients within days of discharge to head off complications that could send them back. He also wants to see formation of a citywide health system coordination office to assess trends and give rise to joint measures.

“There are a half-million people or so that live in Baltimore, and we are responsible for their health and wellbeing,” Callahan said. “It’s shared. Today they are at Maryland, but tomorrow they may be cared for at [Johns] Hopkins or Mercy [Medical Center].”

The hospitals aim to help people such as Christina King, a 45-year-old Brooklyn mother whose repeated flare-ups of diverticulitis sent her to Harbor Hospital multiple times this summer. King said she had lost her job and health insurance earlier in the year. She repeatedly turned to the place she trusted most to address the painful infection in her belly.

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King said after the third or fourth visit in a month, she got a text from the hospital asking what she needed. King said a MedStar representative then helped her navigate the state’s health exchange to qualify for coverage the next day. They found her a primary care doctor and specialist and made her appointments.

“I explained I had no insurance, and I found the state [exchange] site confusing, and she said, ‘I can help you,’ ” said a grateful King. “I also have anxiety and depression, and with insurance I can get back on track with medicines.”

Experts say the percentage of patients needing such assistance is relatively small, especially in states such as Maryland that expanded Medicaid, the federal-state health program for low-income residents. The number is ticking up some, though, since the official end of the coronavirus pandemic emergency and more people find themselves cut from Medicaid rolls.

Patients like King have outsize effects on the health system, especially when cases aren’t as easily fixed as hers. Those with unaddressed mental health or substance use disorders and housing and food instability can be far more complex, time-consuming and costly for health care workers.

As Everett said, “If there are 50 people in the waiting room, who has time to research housing programs?”

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Until recently, there was also little evidence that the efforts were worth it, said Katherine Hempstead, a senior policy adviser at the Robert Wood Johnson Foundation, which has funded similar programs.

A study of a nonprofit community program in New Jersey called the Camden Coalition, which operates programs with goals similar to Maryland’s, found it failed to reduce hospital readmissions generally. But when researchers looked more closely at those most likely to frequent the emergency room, once referred to as super utilizers, they found a significant reduction in readmissions. The findings were published in 2019 in the journal JAMA Network Open.

“There are still repeat users; no one claims to have solved all those problems,” Hempstead said. “But it helps people think about things differently.”

These programs have become far more common nationally as evidence emerges, said Logan Kelly, senior program officer at the Center for Health Care Strategies, which collects and shares information about efforts that are successful.

But she agrees that it can be hard to assess how well they work initially. Figuring out how to pay for the programs or getting insurers to reimburse for services is still a work in progress. She doesn’t even know precisely how many programs exist.

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“The challenge is tracking them, as they are all embedded in different systems and have different names and work with different populations, and there’s not a clear definition of who needs the programs and who is getting assistance,” Kelly said. “But they have common themes, and we are learning from them.”

There are several examples in Maryland — many, like Harbor, flagging people in the emergency room for services. At Luminis Health, the Transitional Care program applies to patients who come to the emergency department but also those admitted to Anne Arundel Medical Center or Doctors Community Medical Center in Prince George’s County. Patients in the Luminis program had just a 1% rate of unplanned readmission in the past year, down from an expected readmission rate of about 20%, by ensuring that patients got timely follow-up care, according to Steve Blau, the system’s senior director of care management and transitional care.

A program at LifeBridge Health’s Sinai Hospital in Baltimore and Northwest Hospital in Randallstown also uses navigators to connect their biggest utilizers to services. At Carroll Hospital, a program for emergency patients specifically allows them to get same-day or next-day follow-up appointments.

The MedStar program is funded with grants and resources at four hospitals, including Harbor, Good Samaritan, Union Memorial and Franklin Square. They have assisted 250 patients, those flagged at registration for having four visits in 90 days.

There are multiple people coordinating medical and non-medical needs, including case workers, community health advocates and peer recovery counselors.

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Jackie White, one of those counselors, is called on to help build trust and steer people to assistance. Those with substance use disorders typically require time for them to accept help, she said.

“I’m easy to talk to,” she said. “I hear their problems. I plant a seed.”

Staff members understand they sometimes have to be patient, said Dr. Lucas Carlson, director of health care transformation at MedStar in Baltimore. But he said they are buoyed by progress.

“No one wakes up and says. ‘I want to go to the emergency room,’ ” said Carlson, also an emergency doctor at Union Memorial. “They have some unmet need. How do we address that need outside the emergency room so they don’t have to come back?”

Meredith Cohn is a health and medicine reporter for The Baltimore Banner, covering the latest research, public health developments and other news. She has been covering the beat in Baltimore for more than two decades. 

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