ER’s frequent flyers have unmet mental health needs

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Rocky Mountain PBS I-News


Call them frequent flyers. Or superutilizers. Or loyal customers. 


In hospitals across the country, they’re known to doctors and nurses as the people who come back time and again for care. 

A very small percentage of patients, they rack up an inordinate share of medical expenses, often preventable. Among Colorado Medicaid enrollees, they spend an average of around eight times as much as their peers. 


And many of them — nearly three-quarters by an Aurora study’s recent count — have a mental illness. 

It makes intuitive sense, and research confirms it: A troubled mind can take a toll on the body, and vice versa. 

This simple fact is leading medical professionals and health officials in Colorado to rethink how to curb high costs in the health care system. What they have found is that it’s impossible to treat the most expensive customers of emergency rooms and other hospital services without addressing mental health.

“You can’t improve the overall health if you’re not treating the whole person,” said Dr. Angela Green, who co-directs an Aurora-based project called Bridges to Care. 

Health care costs, many of them preventable, rank among the highest indirect impacts of mental illness, an analysis by Rocky Mountain PBS I-News has found. 

Medical expenses associated with mental illness reached an estimated $2 billion in Colorado in 2013, according to 2005 figures from the federal Substance Abuse and Mental Health Services Administration, updated for growth and inflation.

Lost wages cost even more. Workers with mental disorders earn $16,000 less per person, according to a 2008 study published in the American Journal of Psychiatry. I-News estimates Colorado’s share of these lost wages at $2.9 billion. 

The costs keep piling up: $425 million for disability pay in 2012, according to the Social Security Administration; $62 million in state education spending for children with emotional disorders in 2012; $44.7 million to hold inmates with mental illnesses in seven county jails, according to a 2010 City of Denver survey of the metro Denver counties; $28 million budgeted this year to treat state prison inmates.

“We’re spending a lot of money on mental health, but in all the wrong places,” says Moe Keller, a former state legislator and advocate with Mental Health America of Colorado. “We’re spending an inordinate amount of money in jails because we’re not treating mental health as a physical health issue, in courts because we’re not treating mental health as a physical health issue, in emergency rooms, in prisons.” 

Keller believes the money would be more wisely directed to the front end, to screening for depression in primary care offices and treating people for mental and physical health problems in the same place. 

Around the state, health officials and hospital administrators are coming to the same conclusion. And they’re starting with the frequent flyers.


Treating the whole person

Christina Jackson seemed to sleep only an hour at a time after her sister died in March 2013.  Her daughter had to coax her to eat. She cried a lot. And then, in July of last year, chest pains punctuated a crying jag. Jackson was having a heart attack. 

One thing led to another. The heart attack was followed by a stroke that left Jackson, 47, blind in one eye. Her hopelessness and anxiety deepened.

By last fall, Jackson had visited the emergency room at University of Colorado Hospital in Aurora three times in a span of six months — the tipping point that alerted Bridges to Care to intervene. 

Bridges to Care, which is run out of Metro Community Provider Network safety-net clinics in Aurora, launched its frequent-flyer program last year. The program, funded by a federal grant, is part of a national movement aimed at stemming health care costs by improving the way care is given to the most costly consumers in the medical system.

In Colorado, this idea is gaining ground in scattershot efforts launched by state Medicaid administrators and hospitals including Denver Health. 

These efforts diverge in how they flag frequent flyers and facilitate care. But they share a philosophy of coordinating services and giving personalized attention to help people navigate a complex health care system more efficiently. 

Relationships are key.  It’s these relationships — between care coordinators and the patients — that can help turn up the undiagnosed and untreated mental illness beneath the surface of a medical crisis.

Along with getting a care coordinator, each person who enrolls in Bridges to Care receives a home visit from a therapist and a psychiatric nurse practitioner. 

The Aurora project has collected detailed profiles of 57 people who have graduated from its two-month program.  Around 72 percent of them were diagnosed with one or more mental illnesses. About a quarter of them had depression, 20 percent had anxiety disorder, and 11 percent had bipolar disorder. 

Bridges to Care’s findings are in line with what health officials and doctors are seeing across Colorado.