More and more these days, emergency room staffs see a stream of patients who shouldn't be there.
There are uninsured people with sinusitis or ingrown toenails. Parents who bring in babies with everyday problems like diaper rashes or runny noses. Some patients are insured, but don't know who their assigned doctor is or can't get an appointment.
At least one in four visitors to Sutter Health's emergency rooms in Sacramento has problems better suited to a regular doctor's office or urgent-care clinic, the company reports.
"It's very expensive, and it's not allowing people who have true emergencies to access the emergency department as it was intended," said Holly Harper, community benefits manager for Sutter's Sacramento Sierra region.
Sutter is working with the Effort, a local nonprofit health care provider, to attack this problem precisely where patients are most open to getting help: at their hospital bedside.
The companies created a new job description, the emergency department navigator. Full-time navigators station themselves in the emergency rooms at Sutter General and Sutter Memorial in Sacramento. They cover the peak hours when patients tend to arrive with non-urgent complaints, between about noon and 8:30 p.m., seven days a week.
The hospital staff alerts the navigators to any patient who doesn't have good prospects for follow-up care such as those who have no insurance, aren't enrolled with a primary care doctor, have mental health problems or are homeless.
The navigators visit those patients' bedsides and offer to help connect them with insurance, doctors, services and housing programs often run by the Effort itself before the patients leave the hospital and return to the tenuous situations that landed them there in the first place.
"If someone felt bad enough or urgent enough to be here, it's a teachable moment, and we want to capitalize on that motivation," said Jonathan Porteus, chief executive officer of the Effort.
On Monday, a 25-year-old former college athlete had reached that moment in the Sutter General emergency room. Pierien Inniss, once the starting center on Encina High School's basketball team and a star sprinter at Oklahoma Baptist University, was homeless and feeling suicidal again.
Inniss said he left his mother's home in Carmichael three months ago because the two argued a lot. He's been living on the streets in downtown Sacramento and checked himself into Sutter with suicidal thoughts for the fourth time since January. Sutter psychiatrists had diagnosed him with bipolar disorder and schizophrenia, he said.
Navigator Angelica Bañuelos, a cheerful social worker, questioned Inniss about his needs, as he responded with a flat voice and sad, distant eyes.
"Do you feel if we could find housing for you it would make things better?" she asked.
"Oh yeah, a lot," he replied.
A 'perfect storm' hit
The patients assisted by navigators have diverse problems. Last week, Bañuelos counseled a 57-year-old Sacramento resident with a severe toe infection, possibly needing amputation. The man, self-employed in software sales and consulting, had stopped paying for insurance last year when his premiums spiraled to a price he couldn't afford.
Bañuelos offered to help the patient get an appointment with Sacramento County's Medically Indigent Services Program, which serves those who can't afford insurance but don't qualify for other public coverage.
"Unfortunately, a lot of times with health care it takes beating somebody's door to get things done, and I'm willing to do that," she said.
Sutter and the Effort tested the navigator program between fall 2010 and fall 2011, and made it permanent last November.
They already had seen success with a program called Triage, Transport and Treatment, or T3, which targets the emergency room's "frequent fliers" those who visit most often. Most of these patients are homeless and have mental health and drug or alcohol abuse problems. By delivering them straight from the hospital into housing, case management, regular medical care and mental health treatment, Sutter and the Effort saw those patients' return visits to the emergency room drop by 65 percent.
They wanted to expand that effort and try a scaled-down approach for patients with somewhat less severe problems.
"What happened was the perfect storm," Sutter's Harper said. "The economy tanked, people lost their health care, the county clinics closed."
The navigators made 881 referrals to insurance, medical, income, housing and other services in 2011. They can't be sure how many patients followed up on those referrals.
In about half her cases, Bañuelos said she's able to assist beyond just giving out information, which makes patients more likely to follow through. She might make appointments for patients, help them fill out paperwork or even accompany them to a doctor's office.
She enrolled Inniss in the T3 program and told him that once he has housing, case managers can help him get food stamps and county mental health treatment, and look for a job. She gave him her cellphone number, as she does for all the patients she sees.
"I got to start taking medicine, start taking things seriously so I can get better," Inniss said.
Solano expansion possible
Sutter is developing a way to measure the navigators' effect on emergency room use and cost savings. Even without hard numbers, Harper is certain the program is having a positive effect on patients so much so that Sutter is looking to create a similar system in Solano County.
Sutter pays the Effort, which employs the navigators, about $150,000 a year to run the program.
Porteus estimated that 60 percent of the navigators' referrals were to services run by the Effort, which is fine with Sutter. The Effort is one of the few local health centers that's "federally qualified," meaning it receives extra reimbursement from the U.S. government to see patients with no insurance or with Medi-Cal. Those federal dollars are crucial to keeping community clinics afloat, so Harper said Sutter wants to help strengthen the clinics in Sacramento.
"They can see people where they belong, in a primary care setting," Harper said.