Everyone in Clearlake knew Charlie. You could find him in the park, sleeping on a bench, or around town adding to his impressive list of transgressions. In a single year, Charlie racked up more than 35 skirmishes with law enforcement, 25 hospital visits, and 16 emergency transports. By most accounts, he was a burden to the system.
Many of us in health care have treated dozens, if not hundreds, of patients like Charlie (we’re using a pseudonym here). Millions of Americans like him — victims of poverty, inequity, mental illness, and circumstance — get caught in an unending loop of incarceration, hospitalization, and hardship. It’s more than morally unacceptable; it’s economically unsustainable. The Agency for Healthcare Research and Quality estimates that vulnerable individuals account for just 5% of the population but half of all health care resources.
For years, communities across the country have turned a blind eye to people like Charlie. In 2017, residents in the small, northern California town of Clearlake decided to respond with a radical experiment in compassion.
Called Project Restoration, this county-wide collaboration includes representatives from law enforcement, emergency services, nonprofits, municipal and health agencies, and faith organizations. It took a new approach to providing proactive, unconditional, and comprehensive care. Charlie was its first case.
A local health care provider and a police officer began the process by visiting Charlie in the park. They asked him a single question, “Will you tell us your story?”
Charlie was skeptical, and didn’t answer.
They returned a few days later, this time with food and water, and asked again. Still nothing.
As trust grew between the team and Charlie, so too did their rapport. Charlie told them he had lived in Lake County for more than 25 years. He had been married, had children, enjoyed his work, and had been a sponsor in the local Alcoholics Anonymous group. After a few hard losses, he started drinking again, losing his marriage, his home, and his job.
“I’ve been living in the bushes ever since,” he disclosed.
The team asked a second question, “What matters to you, Charlie?”
“I just found out I’m going to be a grandfather,” he said, simultaneously smiling and choking back tears, “but my family won’t let me meet my granddaughter until I get sober.” He wanted to get well enough to meet her.
The Project Restoration team members rolled up their sleeves.
Within days, Charlie was admitted to an inpatient detox unit. While he focused on recovery, they focused on housing. Working with area agencies, they transformed a local motel into transitional housing. Churches got involved, renovating the interior of the building and preparing meals. By the time Charlie left rehab, Restoration House had opened its doors, becoming Charlie’s first stable home in more than a decade.
What’s more, all of this was accomplished not by a sizable financial investment, but with savings projected — and ultimately realized — from reduced use of the health system by Charlie and others and savings from unreimbursed care.
Project Restoration didn’t just save Charlie’s life. It also transformed Clearlake.
As one of us (LH) described in a recent TEDx talk, In less than a year, its approach yielded a 44% reduction in hospital utilization, an 82% reduction in use of the community response system, and a 45% reduction in hospital costs among the high-use population. The project is freeing up resources, sharing data across agencies, and creating cross-sector teams to address access to affordable housing, transportation, and behavioral health. Project Restoration leveraged its success to secure a $1.6 million grant to develop a center for integrated support services. In partnership with the Camden Coalition’s National Center for Complex Health and Social Needs, the project is extending the concept to more hospitals and stakeholders.
Perhaps most important, this small community has discovered the power of shared purpose and collective action.
This story isn’t an example of the exceptional. Project Restoration is an example of the possible: a workable, effective approach to healing people and communities.
It’s an approach we are seeing work in locations nationwide — from rural California to urban Memphis — where cross-sector collaboratives are reducing costs and improving outcomes for vulnerable populations.
We are often asked why health systems and communities should care for folks like Charlie. It’s easy to answer with data on savings and reduced resource utilization. Instead, we think of Charlie’s granddaughter. She didn’t meet the Charlie that everyone in Clearlake could find in the park, sleeping on a bench and getting in trouble with the law. She met the Charlie we know: a man whose journey to recovery inspired a community to come together in a radical experiment in compassion.
Lauran Hardin is the senior adviser for the Camden Coalition’s National Center for Complex Health and Social Needs. Shelly Trumbo is the community integration executive for Adventist Health System, a Project Restoration partner.
It’s all about the Benjamins. And it’s not just the homeless. There is much more than 5% of those at or below poverty level who are stuck there because they can’t get the mental or medical help needed. They are only capable of the scut work no one else wants to do. But they only have state health insurance, and you don’t get the best services with those because providers who are well trained are out there making money and can’t afford charity, or sliding scale, patients. There’s tons of people walking around barely surviving, and putting on a good show, because they have probably tried getting help and have banged their head against the wall in frustration because no one cares. And it will probably be passed on to their kids and on down the line. That’s a lot of generations that could be beneficial to society if society should ever grow up.
Around here, they expect you to make it or lose assistance. They run the homeless off to neighboring cities who run them off again. And those homeless steal to survive. And the public wonders why law enforcement doesn’t do something. We’ve tried prisons…they’ve consistently failed. And surprise…the prison population keeps growing. When do people wake up and realize if something’s not working, you don’t throw more resources into it but look for another solution?
Charlie needs a higher level of care than living a homeless lifestyle. He needed to be put on a temporary hold. Then a 31 day hold. Then a conservatorship. He could then be placed in a locked level of care. This level of care could gradually be reduced as his ability to function in a lower level of care improves.
There is nothing new or groundbreaking here. We have known all along that housing and basic need being met, leads to less expensive hospitalization. In the US instead of applying a fact based, realistic approach to all of these basic facts, they chose to mislead the public and increase the trauma on these individuals. This should have been a no brainer, at our local Er, they refer to these people as “Frequent Fliers” and in order to dissuade them from seeking medical care, they treat them harshly. They do the same with any lower income individual, or the under-insured. One would think that seeing the same person day in and day out for years, might be incentive to fix the broken system. Instead they found ways to monetize it, by sending these people to various charity clinics around town. This way they can avoid providing any medical care, and give the appearance that they “helped.”
When people in dire straights showed up, in fear of losing their homes or jobs due to a medical issue, they were sent away either shamed, misdiagnosed or undiagnosed. This went on for years. They added to the crisis, and portrayed all low income people as alcoholics or drug addicts. Even when the addicted showed up time and again, with diseases from injecting drugs, they maximized their billing, by only treating the most serious repated infections.
This is America people, where a profit can be made off of anyone’s misfortune, and there are no ramifications for this almost genocidal targeting of the sick and vulnerable.
A prosperous society *must* accept that a small percentage of its members will need publicly-funded support for long periods, especially since our society fails to guarantee the basic social-medical support at every point in life that could prevent more “Charlie”s.
Regarding the high failure rate of alcoholism treatment programs, the cause is completely non-evidence-based models of treatment, e.g. AA and psychotherapy. Much higher rates of long-term recovery would be possible with protocols developed and proven by people like Julia Ross (https://www.juliarosscures.com) and John Sinclair (https://www.theatlantic.com/magazine/archive/2015/04/the-irrationality-of-alcoholics-anonymous/386255/)
I was disturbed to see this comment in the story.
It is often repeated in various reports.
“The Agency for Healthcare Research and Quality estimates that vulnerable individuals account for just 5% of the population but half of all health care resources.”
I’m afraid that this is a signal that “vulnerable people” be triaged out of the insurance systems.
Government and private insurers hate to see anyone use the service.
Ideally, they want clients who pay the premiums but don’t make any claims against the insurer.
Arson insurers have tried to solve this problem by declaring some neighborhoods as “not insurable” because they have a high incidence of fires.
This helps home insurance agencies approach the ideal:
The homeowner pays the premiums but never submits a claim.
Health insurance has the same dream:
They will insure “non-vulnerable” people only.
Then they can collect the premiums but never pay out for any health care.
So they are always quick to blame certain demographics for consuming more health care than their premiums pay for.
They advocate “para-services” to delete these “vulnerable” people from their insurance pool.
Unfortunately, the 5% of heavy users includes the newborn and the elderly — two of the groups who need the most medical care.
By crafting their information carefully, the insurers want to make people believe that it is unfair for these people to use so much health care.
They are hoping to triage off the elderly into “para-services” so they’ll stop using up health care just because they are obviously going to need more.
Unfortunately, recovery from alcoholism is not certain to be permanent.
And Charlie is not self-supporting.
Rather, the costs of his care have only been reassigned to other social agencies.
amazing story. strangely, when I was doing medical transcription while being motel homeless, the nice people at the hospital didn’t greet me joyfully as a frequent flyer. Instead they told my partner and sister I wouldn’t survive the night. Guess the joke’s on them: it’s been 10 years and Awesome Partner and I regularly walk 10 miles a week to go birding. I would’t see an American anything to make a profit health care even if I thought I was dying.
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