Last January, Erni Banks found herself in a place she’d come to know all too well: the Emergency Department at University of Colorado Hospital (UCH). As had happened in many winters past, Banks had come to the ED for treatment of a respiratory problem that turned out to be pneumonia.

“It had happened to me every season for three or four years,” Banks said.

Pneumonia was only one of Banks’s problems. Her blood pressure was “sky-high” – she remembers it as 285 over 175 – and she was limping about on knees that were “worn out.” Banks, 61, admits she wasn’t much in the mood for talking when an individual came to the door of the ED exam room and asked to talk to her about a program called Bridges to Care (B2C).

The program, which is spearheaded by Metro Community Provider Network (MCPN) with assistance from UCH, is designed to help people like Banks who have been frequent users of the ED and the hospital. The person who spoke to Banks was a community health liaison – a position shared by MCPN and UCH. She explained that B2C could help connect Banks with primary care and other health care services in her community (see accompanying story, this issue). An MCPN provider would make home visits to assess her needs and a coordinator would help arrange services and act as a navigator through a health care system that can be difficult for the average person to negotiate.

Banks was initially reluctant. She’d lost her job and had to move into an apartment in southeast Aurora leased by her son. “He doesn’t like anyone coming by,” Banks said. But after a time, she reconsidered.

“They were offering to do me a service, and I was curious about what they could do,” Banks said.

A better place

Today, Banks is in a far better situation than she was on that day in January. She completed the 60-day B2C program in June and sees a physician assistant (PA) at an MCPN clinic regularly. She takes four medications to control her blood pressure, is rehabilitating her surgically repaired knees and an arthritic right shoulder, and has gotten mental health services for depression. She is managing her own health with a much-needed helping hand from the B2C program.

The key to that assistance was twice-weekly home visits from Jamie Vader, PA(C), who devoted time to identifying Banks’s needs and answering her questions. Amber Russell, a clinical care coordinator with MCPN, took on the seemingly mundane tasks that often spell the difference between patients getting care that improves their health or cycling from one preventable ED visit and hospitalization to the next.

For example, Banks had Medicaid coverage and had been assigned a primary care provider (PCP), but the office was in Parker. That was a world away for a woman with two bad knees and no car. Russell helped to set Banks up with a PA at an MCPN clinic just a few miles from her apartment – and easily accessible by RTD bus with a discount pass. Those changes made it much easier to keep appointments with her PA, as well as a behavioral health professional in the same building. Russell also assisted her in getting a free eye exam and eyeglasses from Onesight Vision Van, striking down another barrier to getting care.

Without assistance, any of Banks’s medical and behavioral health issues, combined with her scant resources, probably would have meant return trips to the ED and possibly hospitalizations. There is no magic to the fact that she has been able to avoid that, Russell said.

“We’re giving her back the power to manage her own health,” she said. “We’re able to give patients the resources to empower themselves. A lot of that is about starting where the patient is at.”

Many patients are ready to make the same choice, said Jennifer Wiler, MD, MBA, vice chair and associate professor with University of Colorado School of Medicine’s Department of Emergency Medicine. Wiler helped to promote and maintain UCH’s connection with the B2C program.

“Patients have to understand the options available to them,” Wiler said. “We can help them to be educated consumers and help them with decisions about how to access the health care system.”

Front-end investment, back-end savings

There is evidence that the approach pays off, both for patients and the health care system.

ED and hospital utilization fell by roughly half for 225 B2C patient graduates. That helped to save nearly $8 million in combined charges over the three-year program. That’s a solid return on investment on a $4.2 million federal grant, which paid for B2C through June 2015.

For B2C to succeed, providers must invest far more time than is available during a typical clinic visit, Russell said, but it is also essential that patients commit to change. Banks takes an active role in managing her own health. She uses a cuff to monitor her blood pressure and has learned techniques to manage her pain and depression. Five months after graduating from the program, she remains in contact with Russell to ask questions and request help when she needs it. For example, Banks was hospitalized last summer because of a post-surgical knee infection. After she was discharged, she called Russell, who helped her reconnect with her PCP.

“Erni was engaged and wanted to be medically stable,” Russell said. “She was excellent at following through. She took hold of making her health her own responsibility.”

Things aren’t perfect – Banks is still out of work, dealing with pain, and living with her son – but she says she now has far more options than she had that day in January.

“It’s easier knowing that there are people out there that have answers,” Banks said. “If you give me the time, I’ll work on it myself.”