Daily, around 200 to 300 patients flock to the Barnes-Jewish Hospital emergency department in search of medical attention — many in distress, all seeking solutions, healing, and optimism. Amid the relentless activity and intensity, WashU Medicine doctor Randall Jotte, MD, contributes something different: a calm assurance and a boost in morale. On a recent rainy Thursday, security personnel at the entrance engaged him in conversation, while triage nurses greeted him with waves and smiles as he navigated the examination areas, taking a moment to inquire how a patient-services concierge, recently assigned to the department, was adapting to her second shift of work.
Jotte’s kindness and poise have served him well throughout his 24 years — filled with unpredictable experiences — in the Barnes-Jewish emergency department. Nevertheless, he admits there are occasions that unsettle him, including one in October 2012 that altered the course of his emergency medicine career.
He had been tasked by the then-head of emergency medicine to establish a practical care-management strategy for a middle-aged man without stable housing, suffering from persistent blood clots in his lungs. Documentation collected by the chief resident at that time revealed that the patient had been admitted to Barnes-Jewish and several other local hospitals 76 times in the preceding two and a half years; the reasons were unclear. To start untangling the issue, Jotte devised a color-coded calendar that monitored the days of inpatient admissions at various hospitals over a three-month duration. He was astounded by the findings.
“It resembled a baseball team’s schedule, with different colors indicating home and away games — he spent three days here, three days there, five days here, seven days there,” Jotte stated. “We understood that this patient was essentially living in hospitals.”
Very little had changed in terms of the patient’s health conditions or care plan, despite hundreds of hospitalizations over the previous decade, during which he had accumulated a series of diagnostic tests and CT scans, all yielding largely similar assessments. Such frequent visits can strain the medical system, as managing resources for patients whose issues could be better addressed in non-emergency venues means that others might experience longer wait times for care. For Jotte, this case presented a chance that highlighted a fresh perspective on the care required for unhoused patients.
“That patient prompted me to start exploring this issue,” Jotte remarked. “In emergency medicine, you generally see patients for a brief period, making it challenging to truly understand their everyday circumstances. We seldom have the opportunity to rethink how we provide their treatment — but this case was a chance for transformation.”
Innovative strategies for ‘recognizable faces’
For Jotte, this episode sparked the inception of Hospital to Housing, a groundbreaking initiative launched in May 2019 aimed at enhancing medical outcomes and lowering costs by offering housing assistance to stabilize the lives of certain frequent users of the emergency room. The program, chiefly funded by The Foundation for Barnes-Jewish Hospital, has significantly impacted the lives of at-risk patients and curtailed medical expenses. Data from the pilot phase indicated that emergency room visits among participants decreased by 53%, while inpatient admissions dropped by 42%. The estimated savings for Barnes-Jewish was $12,500 per participant. More than 70 individuals have participated since the program began.
The initiative would not have come to fruition without examining the broader context of the patient’s narrative.
Kelly Hanselman, the emergency services director at Barnes-Jewish, noted that “recognizable faces” — patients who frequent the emergency room far more than average patients — may appear a few times each month; while others might come in several times a day. Some may endure home environments characterized by violence or abuse. Others might grapple with mental health issues or substance use disorders, which can lead to or exacerbate chronic health concerns.
For these latter patients, Jotte often becomes the primary physician assigned to treat them. He intentionally incorporates his insights regarding this demographic into his education of WashU Medicine students and residents.
“He has a smile that encourages patients to share anything, and he genuinely listens, irrespective of how long their stories may be,” said Arrianna Thompson, MD, a previous clinical fellow in the Department of Emergency Medicine, now practicing in Milwaukee. She volunteered with Street Medicine St. Louis to deliver medical outreach for unhoused individuals in the city and frequently collaborated with Jotte in the emergency department.
Read the complete story on the WashU Medicine website.
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