How Oregon health reform got 'frequent flyer' out of ER

Forty-year-old Jeremie Seals has had a tough life. He left home at 14 and his health isn't good.

As part of a pilot project, Pearlstein guides patients like Seals through the medical maze.

Seals explained, "I have congestive heart failure. I have cardio myopathy. I have neuropathy in both my legs really bad. I have had a heart attack when I was 35 and I am, long story short. I'm terminal."

His doctor, Christina Milano, has given him two troubling pieces of information. First, that he'll die without a heart and kidney transplant. And second, he's about as likely to get a transplant as he is to win the lottery.

Seals said, "It's because my heart wouldn't handle the duel operation."

Over the years, Seals has worked at fast food restaurants and gas stations. But his health has deteriorated to such a degree he says, that he can no longer hold down a job. In 2011, he was sleeping in his car.

Jeremie Seals: "I basically lived at the emergency department. Ever since I'd had a heart attack, anytime my chest hurt, I'd either call the ambulance or go up to the hospital. and I think it was also out of desperation to just get out of my car and off the street."

That year, Seals visited the Emergency Department at OHSU about 15 times. He also had 11 inpatient admissions.

Essentially he was what's known as a "frequent flyer." Health experts say people who use the healthcare system in this way help to explain why 80 percent of the nation's health care costs are spent on 20 percent of the population.

And that's what brought Seals to the attention of Oregon's new coordinated care organizations — and specifically Lisa Pearlstein.

She's an outreach worker for Health Share Oregon, to which Seals was assigned as a member of the Oregon Health Plan.

As part of a pilot project, Pearlstein was tasked with guiding patients like Seals through the medical maze - away from repetitive and expensive ER visits and towards regular doctor visits — to stabilize their health.

In fact, it was at an appointment with Dr. Christine Milano in 2011, that Pearlstein first met Seals.

Pearlstein said, "And she's talking to him, examining him. He's sitting in a chair and complaining about his feet being wet. And I said, 'Why are your feet wet?' And he said, 'I have holes in my shoes.' And I said, 'Would you like a new pair of shoes?' And so I ended up getting him a new pair of shoes that day. And so we connected over those shoes."

Seals said, "This was during mid winter — my feet were getting saturated, they were freezing. Not only did she get me boots, but she got me a pillow and she got me a really awesome sleeping bag. Like a sub-zero sleeping bag."

The new health reforms allowed Pearlstein to buy such non-medical items for Seals. And from that point on, she took on his case — much as you might expect a family member to do.

So, she helped him schedule doctor appointments. And she attended those appointments — to make sure he understood what he had to do. She also helped him figure out his dialysis and medications.

Pearlstein explained, "He and I would always meet on a Friday, to plan his weekends. Because those were the toughest times. So we made sure he had a place to park his car, that he had a library card, so he could go to the library. That he had passes to go to Dishman, if he needed to have a shower. So just kind of putting together the barebones things he needed to survive to get through the Monday."

Eventually, Pearlstein helped Seals negotiate a spot in adult foster care — so he now has a roof over his head.

She says the two of them built a rapport and he now trusts her. But it wasn't easy:

Seals said, "I understood that Lisa was trying to help me. But at the same time I had a real hard time trusting anybody in the medical field or any field that dealt with medical, period."

That distrust stemmed from previous experiences. For example, Seals says doctors tried multiple times to put a fistula into his arm — it's essentially a point of access for dialysis where blood can be taken out, cleaned, then put back.

He said, "I tell them I want them to knock me out, but they won't do it."

In the past, Seals had grown angry with doctors about his fistula — and walked out of the ER. But he says, Pearlstein has helped him to be more communicative, so that he can explain his needs calmly and clearly.

Pearlstein said, "In our working together it's understanding that as the patient, he does have the right to say, 'No, I'm not going to go through with this.' But it's very hard and it takes a lot of courage to do that because you're in this powerful medical system and they're thinking, 'This time, it'll work.' That's their job to be optimistic and to believe in these techniques but sometimes the human body and the person cannot withstand that experience again."

Pearlstein doesn't give Seals medical advice, but she has helped him build a relationship with his doctor — Christina Milano at OHSU's Richmond Clinic.

He says he now trusts Milano, and she says he's moving in the right direction.

Milano said, "When he has the resources available to him and when housing had stabilized for him, he is actually wanting to be adherent to the medication regiment that I had recommended for him and that his specialist have recommended for him. So essentially providing him clear information and a supportive environment I think has allowed Jeremie to improve his condition and to stabilize his condition."

Milano and Pearlstein worked extensively with Seals for the first few months. Now he has a home, he's medically stable and he's much more on his own.

So, from a health perspective, the coordinated care system appears to be working. But what about the money? Have Pearlstein, Doctor Milano and their team saved the system any money?

CareOregon won't give the specific figures for how much it cost to care for Seals, and he doesn't want that information released. But in the year before Pearlstein started working with him, he visited OHSU's emergency department 15 times and had 11 patient admissions.

The year after, Jeremie Seals visits the ED 4 times and had 3 inpatient admissions. Rebecca Ramsey of CareOregon says those are significant savings - even after taking into account the $3500 it cost to have Lisa Pearlstein work with him one-on-one during 2012.

Ramsey said,"It doesn't take very many ED visits and it takes less than one hospital admission avoided, to actually more than pay for the time that Lisa spent with Jeremie."

Ramsey says just one in-patient admission for someone with Jeremie Seals' medical problems can easily amount to $10, $20 even $30 thousand — depending on how long they stay.

And at those prices, says Ramsey, patients like Seals could get other kinds of services they need, whether it be dialysis, medication or something else.

Meanwhile, the federal government has given Oregon almost $2 billion and five years to show it can reduce the rate of medical inflation here by two percent.

If the state fails, it faces some big fines.

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