How do you help patients who show up in the ER 100 times a year?

Larry Moore defied the odds — he snatched his life back from a spiral of destruction. The question is: how?

For more than two years straight, Moore was sick, homeless and close-to-death drunk — on mouthwash, cologne, anything with alcohol, he says. He landed in the hospital 70 times between the fall of 2014 and the summer of 2017.

“I lived in the emergency room,” the 56-year-old remembers. “They knew my name.” Things got so bad, Moore would wait for the ER nurses to turn their backs so he could grab their hand sanitizer and drink it in the hospital bathroom.

“That’s addiction,” he said.

Then, in early 2018, something clicked, and turned Moore around. Today, he’s more than five-years sober with his own apartment, and has only needed the ER a handful of times since 2020. He’s active in his church and building new relationships with his family.

Moore, of Camden N.J., largely credits the Camden Coalition, a team of nurses, social workers and care coordinators for his transformation. The nonprofit organization seeks out health care's toughest patients — people whose medical and social problems combine to land them in the ER dozens of times a year — and wraps them in a quilt of medical care and social services. For Moore, that meant getting him medical attention, addiction treatment and — this was key for him — a permanent place to live.

“The Camden Coalition, they came and found me because I was really lost,” Moore said. “They saved my life.”

For two decades, hospitals, health insurers and state Medicaid programs across the country have yearned for a way to transform the health of people like Moore as reliably as a pill lowers cholesterol or an inhaler clears the lungs. In theory, regularly preventing even a few $10,000-hospital-stays a year for these costly repeat customers could both improve the health of marginalized people and save big dollars.

But breaking this expensive cycle — particularly for patients whose lives are complicated by social problems like poverty and homelessness — has proved much harder than many health care leaders had hoped. For example, a pair of influential studies published in 2020 and 2023 found that the Coalition’s pioneering approach of marrying medical and social services failed to reduce either ER visits or hospital readmissions.

“The idea that someone should go to the emergency room 100 times in a year is a sign of deep, deep system dysfunction,” says Jeff Brenner, the primary care physician who founded and led the Camden Coalition from 2002 until 2017. “It should be fixable. We're clearly still struggling.”

Yet, Brenner and others on the frontlines of one of health care’s toughest, priciest problems say they know a lot more today about what works and what misses the mark. Here are four lessons they’ve learned:
 

Lesson one: Each patient needs a tailored, sustained plan — not a quick fix

The Camden Coalition originally believed that just a few months of extra medical and social support would be enough to reduce the cycle of expensive hospital readmissions. But a 2020 study published in the New England Journal of Medicine found that patients who got about 90 days of help from the Coalition were just as likely to end up back in the hospital as those who did not.

That’s because, frontline organizations now realize, in some cases this wraparound approach takes more time to work than early pioneers expected.

“That 80th ER visit may be the moment at which the person feels like they can finally trust us, and they're ready to engage,” says Amy Boutwell, president of Collaborative Healthcare Strategies, a firm that helps health systems reduce hospital readmissions. “We do not give up.”

Frontline groups have also learned their services must be more targeted, says Allison Hamblin, who heads the nonprofit Center for Health Care Strategies, which helps state Medicaid agencies implement new programs. Organizations have begun to tailor their playbooks so the person with uncontrolled schizophrenia and the person battling addiction receive different sets of services.

Larry Moore, for example, has done fine with a light touch from the Coalition after they helped him secure stable housing. But other clients, like 41-year-old Arthur Brown, who struggles to stay on top of his Type 1 diabetes, need more sustained support. After several years, Coalition community health worker Dottie Scott still attends doctor’s visits with Brown and regularly reminds him to take his medications and eat healthy meals.

Aaron Truchil, the Coalition’s senior analytics director, likens this shift in treatment to the evolution of cancer care, when researchers realized that what looked like one disease was actually many and each required an individualized treatment.

“We don’t yet have treatments for every segment of patient,” Truchil says. “But that’s where the work ahead lies.”

Lesson two: Invest more in the social safety net

Another expensive truth that this field has helped highlight: America’s social safety net is frayed, at best.

The Coalition's original model hinged on the theory that navigating people to existing resources like primary care clinics and shelters would be enough to improve a person's health and simultaneously drive down health spending.

Over the years, some studies have found this kind of coordination can improve people’s access to medical care, but fails to stabilize their lives enough to keep them out of the hospital. One reason: People frequently admitted to the hospital often have profound, urgent needs for an array of social services that outstrip local resources.

As a result of this early work, Hamblin says, state and federal officials — and even private insurers — now see social issues like a lack of housing as health problems, and are stepping in to fix them. Health care giants like insurers UnitedHealthcare and Aetna have committed hundreds of millions of dollars to build affordable housing, and private Medicare plans haveboosted social services too. Meanwhile, some states, including New York and California, are earmarking billions of Medicaid dollars to improve their members’ social situations, from removing mold in apartments to delivering meals and paying people’s rent.

Researchers caution that the evidence so far on the health returns of more socially focused investments is mixed — further proof, they say, that more studies are needed and there’s no single solution that works for every patient.

Some health care experts also still question whether doctors and insurers are best positioned to lead these investments, or if policymakers and the social service sector should drive this work instead.

Lesson three: Recent boom in new programs demands better coordination 

This spike in spending has led to a wave of new organizations clamoring to serve this small but complex population, which Hamblin says can create waste in the system and confusion for patients.

“All of these barriers to entry and handoffs don’t work for traumatized people,” former Coalition CEO Brenner says. “They’re now having to form new, trusting relationships with multiple different groups of people.”

Streamlining more services under a single organization's roof is one possible solution. Evidence of that trend can be seen in the nationwide growth of so-called Certified Community Behavioral Health Clinics, which deliver mental health care, addiction treatment and even some primary care in one place.

Brenner, who now serves as CEO of the Jewish Board, a large New York City-based social service agency with a budget of more than $200 million a year, is embracing this integration trend. He says his agency is building out four of that newer type of behavioral health clinic, and offering clients housing on top of addiction treatment and mental health care.
 

Other groups, including the Camden Coalition, say simply getting neighboring care providers to talk to one another can make all the difference. Coalition head Kathleen Noonan estimates the organization now spends just 25% of its time on direct service work and the rest on quarterbacking, helping to coordinate and improve what she calls the “local ecosystem” of providers.

Lesson four: Rethink your definition of success, and keep going

Twenty years ago, the goal of the Camden Coalition was to help their medically complex patients stay out of the E.R. and out of the hospital — provide better health care for less cost. Kathleen Noonan, who took over from Jeff Brenner as CEO of the Coalition, says they’ve made progress in providing better care, at least in some cases — and that’s a success. Saving money has been tougher.

“We certainly don't have quick dollars to save,” Noonan says. “We still believe that there’s tons of waste and use of the [E.R.] that could be reduced … but it’s going to take a lot longer.”

Still, she and others in her field do see a path forward. As they focus on improving their patients’ mental and physical health by developing and delivering the right mix of interventions in “the right dose,” they believe the cost savings may ultimately follow, as they did in Larry Moore’s case.

The stakes are high. Today, homelessness and addiction combined cost the U.S. health care system north of $20 billion a year, wreaking havoc on millions of Americans. As health care delivery has evolved in the last two decades, the question is no longer whether to address people’s social needs, but how best to do that.

This story comes from the health policy podcast Tradeoffs. Dan Gorenstein is Tradeoffs' executive editor, and Leslie Walker is a senior reporter/producer for the show, where a version of this story first appeared. Tradeoffs' weekly newsletter brings more reporting on health care in America to your inbox.

Side Effects Public Media is a health reporting collaboration based at WFYI in Indianapolis. We partner with NPR stations across the Midwest and surrounding areas — including KBIA in Missouri, Iowa Public Radio, and WFPL in Kentucky.