David Anthony Cook was still wearing his UC Davis Medical Center hospital bracelet when a Lyft car dropped him off at a Volunteers of America office last month.
Cook, who is 57 years old and homeless, had just spent three days in the hospital after passing out in a parking lot. He was weak and barely mobile, and his clothing was soaked with urine. He carried a plastic bag with a UC Davis logo containing his possessions.
"This man rang our doorbell and was very, very frail and disoriented," said Amani Sawires Rapaski, VOA's chief operating officer. He had been dropped at the agency's Marconi Avenue administrative office, which has no shelter beds or clinical services for homeless people.
Rapaski arranged for Cook to enter the city's winter triage shelter on Railroad Drive, which VOA operates. But his medical condition was too complicated for its staff to manage. So, a few days after his arrival, they sent him back to UC Davis hospital.
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It is a cycle that repeats itself regularly among Sacramento's homeless men and women, and one that the community's pilot Whole Person Care program intends to address. The $64 million program, which officially launched this month, targets homeless people who are frequent users of costly emergency medical services.
Cook appears to be a case study for Whole Person Care.
During his first three months of living on the streets of Sacramento, he cycled four times through UC Davis, the city's only public hospital, according to medical records reviewed by The Bee with his permission.
His visits, each of which began in the emergency room, generated more than 1,000 pages of paperwork detailing dozens of tests and interactions with numerous doctors, nurses, social workers and others who tended to him. In each case, he became homeless again shortly after his discharge.
Emergency room doctors and others who treat homeless patients said the cycle is alarmingly common, and costly to both the patients and the system of caring for them.
"While they're in the hospital, they're getting spectacular care," said Jonathan Porteus, chief executive officer for Wellspace Health, which oversees a network of clinics that treat poor people. "They go from world-class treatment into a community that is not ready for them," said Porteus, who chairs a local advisory committee on homelessness.
The revolving door "is a failure, because we're not changing the ultimate outcome for the patient," said Dr. J. Douglas Kirk, chief medical officer at UC Davis Medical Center and a specialist in emergency medicine.
"An entire community effort is needed to address this issue," Kirk said. "It takes a village. Emergency departments are there to provide for a patient's immediate medical needs, which we do very well. Shouldering the burden of all of these other things is quite taxing on us."
Like Cook, many homeless patients wind up in the emergency room for treatment of problems that could be handled in a clinic or at a doctor's office. They often enter the hospital via ambulance. A 2016 study conducted by a private research company for the city of Sacramento found that the top 250 "persistently homeless" people cost the city and county over $11 million that year in behavioral health care, jail, ambulance rides and police services.
Hospital treatment also is costly. According to a 2013 study by the National Institutes of Health, the median charge for an emergency department visit is more than $1,200. Inpatient care for a few days can generate a bill of tens of thousands of dollars.
The Whole Person Care approach is designed to bring hospitals, behavioral health centers, housing programs and others together to coordinate services for homeless people. Sacramento's program, which deploys teams into the field to respond to patients, is one of 25 such pilot programs in California.
"In the past, we've had people in the field, through various funding sources, to help homeless people," said Mayor Darrell Steinberg. "But they don't necessarily coordinate with one another."
Steinberg, who has vowed to steer 2,000 homeless men and women into housing by 2020, said Whole Person Care team members "are clinically trained to help people navigate a very complex system of care. This is the best hope we've ever had to help thousands of people off of the streets."
Under the program, called Pathways to Home + Health in Sacramento, patients like Cook are to be flagged as soon as they enter the emergency room "as people who need immediate assistance to prevent them from becoming homeless again," Steinberg said. "One of our teams of specialists would ideally meet them right away and envelop them with the support and care that they need," including helping them obtain documents, health insurance, respite care, addiction treatment, shelter and ultimately permanent housing.
Currently, services for homeless people are fragmented, Porteus said. Individual hospitals have different protocols for assessing and discharging such patients. Contact information for behavioral health agencies and shelters sometimes is incorrect or out of date. Communication between various entities that serve homeless men and women sometimes is poor.
The Whole Person Care effort seeks to close those gaps and refine policies and procedures to make them consistent across the board, he said.
It also will provide funding for 16 additional "interim care" beds for people who are well enough to be discharged from hospitals but too sick or frail to survive on the streets, said homeless services coordinator Emily Halcon. Currently the city has 34 of those beds, where people can stay for up to 60 days while case managers work to find services and housing for them.
The Pathways program, funded with $32 million in local dollars primarily from the area's four participating health systems, will receive a $32 million federal match if it meets certain goals. Those goals include reducing emergency room visits by at least 15 percent, referring at least 15 percent more people to treatment for addictions, and finding 15 percent more people permanent housing.
The biggest obstacle to making the program an unqualified success, said Porteus and others, is a lack of affordable housing in the community.
"We could get people through the pipeline if we had adequate housing stock," Porteus said. "Hospitals and shelters are full of people who are eligible for permanent housing, but there's no place to put them."
Porteus and others pointed to the public's response to the opening in January of a waiting list for subsidized housing in Sacramento. Nearly 43,000 people entered a lottery for 7,000 vouchers for housing slots.
Rising rents have made housing unaffordable for many residents. Average rents surged from $862 in 2010 to $1,205 last year, statistics show. Meanwhile, Sacramento's homeless population has increased 30 percent since 2015, according to a recent census.
"We're on life support with the lack of affordable housing," said Porteus.
David Anthony Cook's case helps illustrate the difficulties of finding housing for someone who is poor and has complicated health issues.
Cook's medical records show that he has Type 2 diabetes and a host of other problems related to the disease. He also abuses alcohol and drugs, according to the records.
Cook said he came to Sacramento in February, shortly after moving out of his mother's home in Oakland. His $879 monthly Social Security disability check was not enough to pay rent, he said. He wanted to live with his mother and brother in Clear Lake, he told The Bee. But his brother, Andre Baker, said his family feels unsafe around Cook when he is drinking and using drugs.
"When he's sober and clean, he's the most incredible human being you could ever want to meet," Baker said in an interview. "But he's not the same person when he drinks and uses drugs. I can't have him around my family when he's like that."
A few weeks after leaving Oakland, Cook found himself homeless in the capital city.
"It was cold," he recalled. He slept in a parking garage on 30th Street and carried his clothing and other supplies in a plastic trash bag.
Cook arrived in the UC Davis emergency room for the first time on the afternoon of Feb. 7. An ambulance delivered him after paramedics found him "laying on the ground in a parking lot," his records indicate.
Nurses and social workers noted that Cook had a general delivery address, and that he had an "alcohol problem." After receiving various tests and IV fluids, he was discharged the next day with instructions, prescriptions and "all of his belongings," records show.
On March 19, Cook was back.
Weak from an apparent urinary infection, he had been scooped up by paramedics at 14th and J streets and once again taken to the emergency room.
A doctor described him as suffering from untreated diabetes, a skin condition that had scarred his face, sepsis and "polysubstance abuse including crack cocaine, meth and alcohol." He was incontinent and unstable on his feet.
Cook told a social worker that he "will die" if he stayed on the streets, and asked for help in finding a place to sleep. Staffers located a bed at a room and board, and because Cook had no money or credit cards with him UC Davis agreed to cover his first month of rent. He was discharged from the hospital on March 29 after receiving extensive treatment for his diabetes and infection.
Cook lasted less than a month at his room and board.
On April 10, he again wound up at UC Davis hospital courtesy of the city fire department. Ambulance drivers took him to the emergency room after he was "kicked out" of a diner near 30th and J streets, according to records. Cook complained of dizziness and weakness.
His caregivers wrote that he had been booted from his care home for smoking methamphetamine, and again was living on the streets. Two days later, a nurse wrote in his chart that "current plan is for patient to be transported via Lyft to a homeless shelter," and that Cook had agreed to go.
But the address listed in his records for the winter shelter was wrong. Because of an apparent clerical error, Cook was sent to Volunteers of America's administrative office.
Rapaski of VOA said that, after Cook's arrival, she scrambled to get him a bed at the Railroad Drive facility, even though the shelter's focus is on homeless people in North Sacramento. "It was against protocol, but I felt I didn't have any choice," she said.
The car that delivered him had left, so Rapaski arranged for Cook to be transported by a sheriff's deputy to the Railroad Avenue shelter. He arrived in the early evening, "kind of disoriented, and he had soiled himself. So we helped him clean up, fed him and made him as comfortable as we could," said the shelter's care coordination manager, Anna Darzins. Cook carried no medications or discharge papers, Darzins said.
"I'm grateful," Cook told The Bee the following day. "At least I'm not on the streets."
But it quickly became apparent that Cook's various problems, in particular his lack of mobility and incontinence, were too complicated for the shelter staff to handle. They tried, but failed, to find him a place to live.
So they did the next best thing, they said:
They sent him back to UC Davis hospital.
There, UC Davis received a visit from a Pathways team, which decided he should go to the VOA's alcohol treatment center. As of this week, he remained at the facility.
But his next stop is uncertain.
Although Cook now is surrounded by Whole Person Care, "his medical issues make this a very difficult situation," said David Silveira, director of shelter services for VOA. "It's enormously complicated. We're not sure what we're going to do."