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The emergency department at The Queen’s Medical Center on Punchbowl Street in Honolulu is a busy place.

Twenty-four hours a day, seven days a week, people pour through the doors in medical crisis, often needing lifesaving treatment. On average the Queen’s ED sees just under 200 people per day.

On any given day you might find: An older woman who’s had a stroke and needs medications immediately to save her brain function. A tourist struck in the head by her surfboard who needs a CAT scan and stitches. A man with a fever and cough who worries he may have a serious viral infection.

Such scenarios are what the emergency medicine nurses, doctors, social workers, pharmacists and support staff signed up for. They thrive in this fast-paced, high-stress, life-or-death environment, offering quick and critical thinking and deep compassion to patients facing their worst moments.

But other patients who come to the emergency department challenge the staff in a different way.

These are patients who show up in the ED frequently, sometimes several times a week. They may have diabetes, heart issues, infections — conditions that don’t require emergency care. The ED doctors and nurses ask these patients to see a primary care provider but that rarely happens.

Sometimes these patients will yell. Sometimes they have been drinking or using drugs. Often they are living on the streets. Often their lives are in crisis. Often they make other patients in the waiting room visibly uncomfortable.

They are a small group for whom the emergency department is a place to talk to a doctor or nurse, have wounds attended to, get medication refills, find safety, a place to rest and a sandwich.

Federal law requires that anyone seeking medical care at a hospital must receive a medical screening exam by a provider. Even if a patient was seen and treated just hours earlier for the same condition, emergency departments may not refuse to see them.

Such a case inverts the mantra of best practice medical care: It’s the wrong care in the wrong place at the wrong time.

In Search Of Solutions

In response to such patients —  people frequently using the emergency department for non-emergencies — The Queen’s Medical Center developed the Queen’s Care Coalition program.

Its goal is to connect high-need, high-cost patients with services in the community that will assure patients receive the right care in the right place.

One patient with 16 ED visits in three months that resulted in four hospitalizations was one of the first enrolled in the program. This patient was unsheltered and had been living behind a parking lot for 10 years. He had a mental health diagnosis and a long history of substance use.

He didn’t consistently take medications for any of his physical or behavioral health issues. He was not connected to any resources in the community and refused to go to a shelter or to get any mental health help or substance use treatment.

Through the Queen’s Care Coalition, he was teamed with a community health worker. He was one of just 10 patients the community health worker was caring for. (In many programs, caseloads of 50 or more individuals are the norm. A relatively small caseload allows the frequent, sometimes daily contact needed to get these patients on track.)

Intense navigation services are provided for 30 to 90 days. The community health worker in this case, full of empathy for the patient, began building rapport by identifying his strengths. Surviving behind a parking lot with no support for 10 years is no small feat.

Many people experiencing homelessness live with daily physical and emotional trauma. Sexual assault, theft and violence are pervasive on the street. The subtler emotional injuries of being ignored, avoided and shamed by society take a toll.

For many people who have been living on the streets for years, it takes a Herculean effort to move beyond a fight-or-flight existence amid the struggle for basic human needs like food, water and safety.

Using a harm reduction lens, Queen’s Care Coalition community health workers can acknowledge and attend to the trauma histories that are often at the root of “non-compliance.” They start where the patient is.

For many people who have been living on the streets for years, it takes a Herculean effort to move beyond a fight-or-flight existence amid the struggle for basic human needs like food, water and safety.

Rather than requiring patients to meet program goals, community health workers encourage patients to identify their needs. Together patients and health workers create and agree on an action plan to begin to address those needs. The patient who had had 16 ED visits in three months identified housing as his biggest barrier to care.

Instead of insisting on shelter or nothing, his community health worker joined with the Coalition’s community partners to place the patient in a short-term medical respite bed, and then a boarding home with the ultimate goal of getting him into an apartment.

Most contact with all Queen’s Care Coalition patients is face-to-face: visits in the patients’ chosen location, including parks, sidewalks and homeless encampments. No-shows are not penalized, abstinence from illicit substances is not required and strict compliance with action plans is not expected.

All incremental and small positive changes are celebrated. When the patient visited a hygiene center for a shower, the community health worker lavished him with praise.

Throughout the process of getting the patient a permanent roof over his head, the community health worker continued to build trust. She acted as his advocate, cheerleader, interpreter and ally. She attended all initial appointments and helped his doctor to understand his history. She navigated the complex benefits system to connect him with food stamps and Social Security funds.

Once he had a home, she took him grocery shopping and taught him to cook hamburger steak in his kitchen. After three months, he was ready to graduate from Queen’s Care Coalition. The community health worker and all of the patient’s new community supports met to develop a concrete plan to continue his forward momentum.

He now lives in his own apartment. He attends all his medical appointments on his own and takes all his medications. He has a great relationship with his doctor. He calls the community health worker from time to time to check in. He is doing well and has not been to the emergency department or hospitalized since graduating from Queen’s Care Coalition over two years ago.

The Statistics Show Success

The patient described above is not an anomaly. Since its founding at the beginning of 2018, the Queen’s Care Coalition has helped hundreds of individuals. Looking at data for the period from January 2018 to September 2019, Queen’s Care Coalition provided services to 322 individuals.

In the six months prior to intervention, those 322 individuals visited the Queen’s Emergency Department 2,643 times.

In the six months after they graduated from Queen’s Care Coalition, the number of ED visits by these 322 individuals dropped to 1,218 — a decrease of 53%.

The number of ambulance transports to the ER dropped from 1,290 to 587, freeing up ambulances for actual medical emergencies on Oahu.

In addition to increasing the health and wellbeing of the individuals served, the reduction in unnecessary health care represents a major savings of Medicaid and Medicare dollars.

In the six months prior to his work with the community health worker, the patient described above had a total cost of care — including all inpatient and outpatient services island-wide as well as ambulance rides — of $98,959. In the six months after he was helped by the Queen’s Care Coalition, that cost dropped to $47,172 — a 52% reduction in total cost of care.

Hawaii has many good programs for people who are homeless and struggle with complex medical, legal, behavioral and substance use issues.

These programs are effective in many cases, but some people need more intensive help, and unless they get it, their chronic conditions worsen, the cost of their care rises and good outcomes become less likely.

The Queen’s Care Coalition is designed to target this population, filling in the gaps and helping these people — who are no less members of our community, our neighbors, our friends, somebody’s family — to successfully access the services and care that exists in the community.

The model of small caseloads, frequent contact, harm reduction techniques and goals driven by the patient and not the health worker are most likely scalable and transferable.

They could be adapted to reduce recidivism by people who repeatedly cycle through our jails without ever getting the social, economic, medical and psychological care they need.

The principles could also be applied to help people who are released from prison, and people who are transitioning from a substance abuse treatment program back to the community.

We have seen dramatic improvement in the lives of hundreds of people.

Another patient, for example, is a woman in her mid-60s with multiple chronic medical conditions and psychosis. She had multiple hospitalizations for health issues and at one point was intubated in the ICU.

During that hospital stay, she was connected with a Queen’s Care Coalition community health worker, who helped her through stays at medical respite facilities, shelters and when she was unsheltered on the streets. He helped her reinstate lapsed financial benefits and connected her to mental health case workers and doctors’ appointments.

With the community health worker’s guidance, the patient moved to a group home with supportive services and started medication for her mental health. She has not visited an emergency department or the hospital since. She makes her medical appointments and checks in with the community health worker every few months.

Another participant in the program is in his 70s, a former construction worker living with diabetes. After the amputation of his feet, he can only get around in a wheelchair and was frequently hospitalized.

After each hospitalization, he would ask to be discharged to his car in a shopping center parking lot, where he lived. There he paid another homeless individual to help him transfer from his car to his wheelchair every day. He did not attend follow-up appointments or take his medications.

When he was connected with a community health worker, he agreed to try something different upon discharge.  He went to a skilled nursing facility for IV antibiotics and physical therapy. There he healed and regained strength, and from there he transitioned to a medical respite house. The community health worker helped him establish primary care and apply for financial benefits and foods stamps.

He became motivated to take charge of his health and began to attend daily hyperbaric wound care appointments independently. After 11 years of homelessness, he now has his own apartment, in a building he built while working construction 40 years ago. He has not visited the emergency department since meeting the community health worker.

For those in our community who have been marginalized, forgotten or deemed hopeless, the Queen’s Care Coalition model could be a powerful tool for restoring not just access to care, but hope.

This week’s IDEAS Live show features a conversation on police accountability and reform with University of Hawaii law school instructor Ken Lawson and retired Los Angeles Police Department veteran Randolph Franklin, founder of the Community Council for Police Accountability. Watch at 2 p.m. Wednesday on .