Westchester care team takes on 250 Medicaid ‘frequent fliers’
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YONKERS — In the lobby of a rundown building on the city's west side, two women rang a buzzer over
and over, wondering whether their host may have stood them up.
Bone-thin, fragile yet lively, Linda Pickering, 52, finally lets the women into the apartment they
helped her get after drug abuse and chronic medical and emotional problems sent her to the emergency
room one too many times.
"I wanted to clean up a little before you came in," Pickering said with a broken smile as she opens the
door for a nurse and a peer support specialist. They were with Hudson Health Plan and charged with
checking in on her six months after she joined a program to coordinate her health care.
Pickering was deemed one of the high users or "frequent fliers" of the Medicaid system in
Westchester County.
She and others enrolled in Medicaid, the state-federal health plan for the poor and disabled, cost
taxpayers millions each year when homelessness, addiction, hunger and neglect send them through
the revolving doors of the hospital emergency room.
They are among the 4 percent of Medicaid enrollees nationwide who are responsible for nearly 50
percent of all Medicaid spending, according to a 2007 study.
A state Health Department pilot program developed with Hudson Health Plan may help. The Medicaid
managed-care provider created the Westchester Cares Action Program to coordinate the medical and
mental health care of 250 of the neediest Westchester residents. The state pays Hudson $330
monthly for each person enrolled in the program. Nurses, social workers and case managers at the
Tarrytown organization are given a list of the highest users of the Medicaid system and pound the
pavement to find them.
They knock on doors in public housing or condemned buildings and go to homeless shelters,
food banks and hospitals. They go to great lengths — often unappreciated — to talk to each person and
help them get what they need.
One day they talk to a landlord about getting heat. Another day it's figuring out how to get a new
apartment for a wheelchair-bound amputee living in a second-floor walk-up.
Sometimes, it's just ensuring the clients have a way to get to their doctor's office or teaching them how
to pay bills and shop for healthy food.
The goal is to get 250 of the highest users of the Medicaid system into the program, both to help them become healthier people and to stem the rising costs to the system.
They want addicts to go to support groups, the homeless to live in apartments.
These are some of the first steps, they believe, toward getting the diabetics to test their blood sugar, the heart patients to eat better and the people with bipolar disorder to stay on their medication.
Most of the clients on the list have mental and substance abuse issues, and about one-third are homeless.
"You can't talk to people about taking their medications regularly if they don't have a roof over
their heads," said project executive Margaret Leonard, senior vice president of clinical services at Hudson Health Plan.
Finding the clients has been almost as challenging as helping them. Though the team works with an
extensive network of shelters and hospitals, not everyone qualifies for the program, and since the
program started last summer, Hudson has enrolled 110 of the 250 on the list.
That's where Linda Revill comes in.
Revill, 53, the team's peer support specialist, is a unique and crucial part of the program. She helps the nurses and other case workers communicate with the clients in the program and find them.
"Sometimes they feel like they're in a well. They're stuck in there, and what we have to do is climb down into that well with them," she said.
Revill is no stranger to being stuck in "a well."
It's been more than 20 years since she stopped using crack cocaine, but the memories still haunt
her.
Revill was physically and mentally abused as a child and grew up in the foster-care system. She was 15
and addicted to crack when she gave birth to her first daughter, who was taken from her at the hospital. She, too, was in and out of the system as one disaster after another dropped her into the
safety net.
Revill eventually got help and got clean when she was pregnant with her second daughter at the age of
30. She received her high school diploma, entered Westchester Community College and eventually went
on to graduate from Iona College.
"Someone has to come into their lives and say, 'You
don't have to live like this,'" she said. "It doesn't
happen overnight." She shares her story with the
clients often, as she did on the next stop to the
apartment of Russell Wells, 56, of Mount Vernon.
Three years ago, Wells suffered a stroke after having
been a drug and alcohol abuser for nearly 30 years.
The stroke was an awakening for Wells. But he
continued to suffer from nerve damage associated
from his heart problems and diabetes.
From August 2007 to August 2008, Wells' medical
bills were more than $50,000.
A tall, husky and friendly man, Wells seemed
comfortable with the visits to his cramped yet neat
first-floor apartment.
"I'll be honest. I'm not following my diet," Wells
confessed to Revill and the field nurse, Ana Rosa
Pastrana, when they ask him.
But he proudly told them of a recent night when he
resisted the temptation of alcohol and drugs.
"I don't get high anymore. I don't drink anymore. I
didn't want to die like that," Wells said.
At about $11,000 per client, the follow-up care may
seem costly, but Jim Foy, chief executive of St.
John's Riverside Hospital in Yonkers, said he thinks
it will wind up saving the state much more money.
High users of the system could cost the state
dozens of thousands of dollars each year, Foy said.
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"I believe that it will ultimately reduce the cost of
these individuals," Foy said. "Obviously, we need to
track the data as the program goes on, but I think
it's these kinds of programs the state needs to put in
place to save money."
Wells and Pickering have reduced their emergency
room visits significantly since joining Westchester
Cares Action Program last summer, the team's data
show.
After seven months in the program, they have a
combined two visits to the ER and one in-patient
hospital stay.
The work, however, is far from over.
Pickering needs to go to a support group for her
drug addiction . She also needs a podiatrist to look
at her foot.
Wells suffers from a pain shooting up the side of his
leg, and he claims he's becoming much more
forgetful since his stroke.
They both desperately need to see a dentist.
And then there's the emotional anguish from living a
hard life that both Pickering and Wells continue to
suffer.
"I think they may soon be realizing that our trauma
doesn't go away — but it can get better," Revill said.
