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The Super Users 

To rein in rising health care costs and misuse of emergency services, doctors, firefighters and service providers focus on "hot spotters"

click to enlarge Randall Sluder, a chronic alcoholic, is now sober and has permanent housing, thanks to Spokane Hot Spotters Group. - YOUNG KWAK
  • Young Kwak
  • Randall Sluder, a chronic alcoholic, is now sober and has permanent housing, thanks to Spokane Hot Spotters Group.

Everybody knows Randall Sluder. The homeless shelters. The police. The fire department. The emergency room doctors.

He was a guy who always had a Bud in his hand and enough money in his pocket at the beginning of the month to buy beers for his buddies downtown. He was the guy who'd drink until he was blackout drunk and wake up in a strange place with the cops kicking his shoes. His rap sheet — two pages long — includes more than three dozen minor charges for trespassing and public drinking. In the course of two months in 2012, he was picked up and transported to the emergency room 40 times.

"Randall was a guy who would walk out of one ER and call the ambulance in the parking lot to go to another ER," says Darin Neven, an emergency room physician at Providence Sacred Heart Medical Center.

But Sluder boasts that he's a changed man, and his doctors and case managers say as much. Since he moved into his house eight months ago, he's visited the ER once — after buying a six-pack of beer in February, he slipped down an icy hill near his home and smacked his head on the ground.

"Today is my 120th day of being sober," Sluder announces, eyes twinkling, at his home near Hangman Creek. "I haven't touched a drop of alcohol. A drop. Unbelievable. It's unbelievable for me."

Sluder is a so-called "super user," as Neven says, currently benefiting from intense case management from the Spokane Hot Spotters Group. A collaborative effort led by the Spokane County Medical Society, Providence Sacred Heart Medical Center and the Spokane Fire Department, the group focuses its efforts on the community's most vulnerable and complex people — "super users" like Sluder who cycle through emergency rooms and suck up unnecessary medical services without improving their odds of stability. The group gets them into housing and wraps services — financial planning, medical care, housing assistance and rehabilitation — around them.

"It is the lowest-hanging fruit. You can work with one person and maybe eliminate 100 emergency room visits a year, or you can work with 100 people who have one emergency room visit a year," Neven says. "If we're going to go after this from a resource utilization standpoint, we should go after the one person with 100 emergency room visits."

So far, for Sluder, the approach is working. At 57, he looks 70. He's just over 5-foot-4, with a cheeky smile. His fine gray hair is combed, mustache groomed, and his home is impeccably neat. From a filing cabinet in his bedroom, he retrieves a stack of black and manila folders, all individually labeled. He has one for his receipts, another for court documents, one for SNAP assistance, and two to separate his Spokane County Jail records from his Airway Heights prison paperwork. He ticks off the names of people helping him get his life together: the judge at Community Court, the prosecutor, his doctor, case manager and even the journalist in the room.

"I have a lot of people pulling for me," Sluder says. "It's unbelievable. I praise them every day for helping me, for getting me through this."

When Neven first started working in the emergency department at Providence Sacred Heart, he noticed many patients who'd show up at the ER over and over and over again. But the hospital's care wasn't making a difference in their health or behavior. Most of the time, they were just looking for a place to sleep, or food to eat and respite from the jails or shelters.

"The way our [emergency] system works is they have to do everything possible to make sure you're safe," says Lee Taylor, director of strategic initiatives at the Spokane County Medical Society. "That makes it difficult to deal with patients who are there for the wrong reasons, and patients who aren't going to get the care they need. They need a primary care doctor. They need a behavioral health professional, and they need someone to help them deal with their substance abuse issues. ... The ER isn't going to make them well."

The costs of treating them add up. Emergency room care can cost thousands of dollars. A single ambulance transport to the hospital is a $500 expense. In the United States, approximately 1 percent of patients account for 22 percent of all health care spending. What's most frustrating, Neven says, is that super users inhibit emergency responders' capacity to take care of people in real medical emergencies.

"Someone who is dying can have their care delayed because there is no other social system to take care of these people," he says.

Identified through Washington's Emergency Department Information Exchange, a computer network system that tracks patient visits to hospital emergency rooms statewide, they use emergency medical services 30 to 100 times a year. Neven says they're typically serial inebriates, intoxicated more often than they're sober. They often have a mental illness as well. Half the time, they're homeless. The Hot Spotters group is working with six of them, including Sluder; their goal is to expand to 25 clients by the end of the year and cut their medical, emergency and legal costs by $1 million.

"These are people who live at rock bottom," Neven says. "They've grown accustomed to sleeping outside, being drunk all the time. There's really not much farther they can go."

Every Monday, Sluder rides his Harley about two and a half miles to the downtown library and reports to Judge Mary Logan at Community Court for a second-degree trespassing charge from last April. He's required to take disulfiram — which produces immediate and severe negative reactions when alcohol is consumed — attend weekly Alcoholics Anonymous meetings, group counseling sessions, and submit to two urinalysis tests a month. He's counting down to the end of his probation on May 28; each passing day is crossed out in black pen in a pocket planner.

At the library, Sarah Bates, a community health worker for the Spokane County Medical Society, raves about Sluder's progress. Once a week, he calls her to check in.

"It's hard to even describe. He's so much more articulate. He's very focused. He looks fantastic all the time. He's meticulous now," Bates says. "To think where we were a year ago... "

But deep down, Sluder knows the path to recovery is often a bumpy one.

"My mind is still hurting. It's going to be hurting the rest of my life more or less, you know what I mean? I don't want to fall off the wagon," Sluder admits. "But in the back of my mind still, I got that little bug, saying '[just] one' and that's not good for me. Just that one could get me right back. It's so easy." ♦

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