Lafayette nonprofit helps curb costly hospital readmissions

Richard Mitchell’s studio apartment is no castle. There’s no kitchen, so he cooks on a hot plate. It’s small and dimly lit by two windows and a wall-mounted night light next to the bed.

But the spot near UL Lafayette’s campus is a big step up from living in his 2002 Ford Ranger, especially during a scorching summer.

“I couldn’t imagine being out there now, in a 100-degree heat,” says Mitchell, who, while living in his truck, spent a week in the hospital after heat exposure made him hallucinate and nearly lose consciousness.

Mitchell, 60, is one of thousands of clients Lafayette-based Beacon Connections has helped over the past five years.

After starting out as a grant-funded pilot project in 2017, with the goal of addressing social determinants of health — non-medical factors in a person’s life that lead to worse health outcomes and more frequent use of emergency services — Beacon is now broadening the scope of its services locally and expanding to other areas of the state.

Mitchell thought it would be easy enough to find a place, after losing his spot in a trailer on his late boss’ property. He had a steady income he could prove — his monthly disability check.

But the days turned into weeks and then months, as he scoured newspapers and looked for housing online during his visits to the library, his only way of accessing the internet. He was placed on waitlist after waitlist and never heard back, he says.

When Mitchell left the hospital after his bout with heat exhaustion in 2021, a Beacon navigator — the term the nonprofit uses for its case workers — reached out to him. Within weeks, according to Mitchell, he was placed in housing. In the nearly two years since, he has been to the hospital twice — compared to three visits in the months spent living outside.

In recent years, health care providers, in part due to pressure from the federal government, have become increasingly attentive to the impacts social factors such as housing, food insecurity or a lack of transportation can have on patients’ outcomes and the frequency with which they show up in the emergency room.

“We realized there was a lot of need that we weren’t recognizing,” says Melissa Decell, regional director of case management at Ochsner Lafayette General. “We had a limited view of how much the social factors were really impacting those patients.”

The federal government, through its Medicaid and Medicare programs, has used a carrot-and-stick approach to move hospitals and other healthcare providers to be more mindful of social determinants with the goal of reducing frequent, expensive readmissions.

Based on the average cost of re-visits to the emergency department provided by local hospitals and the number of clients served last year, the nonprofit Beacon estimates saving $6.6 million in costs to the healthcare system in 2022.

In 2012, the Centers for Medicaid and Medicare Services started penalizing hospitals for excess readmissions — patients who returned to the hospital too often, too quickly. In 2015, it introduced a system for tracking factors in addition to injury or diagnosis that are likely to impact a patient’s health outcomes, allowing providers to charge more based on those complicating factors. This year, tracking those factors became mandatory.

One goal of Beacon’s was to assist hospitals in this effort and improve health outcomes. “Part of the reason to do this was to say, yes, it can be done,” says Beacon founder and Executive Director Holly Howat.

In the beginning, much of that work consisted of information gathering and data collection, says Decelle, who has been involved in the partnership with the nonprofit since its inception. Patients come in, they’re diagnosed, treated and prepared for discharge, she says.

But do their circumstances allow for them to continue with the treatment plan as instructed or care for their wounds on their own?

“Once that patient leaves our hospital, we don’t have a lot of follow-up communication with them, unless they re-enter as a readmission — which is what we’re trying to prevent,” notes Decelle. Beacon helps fill that gap by keeping track of additional needs and finding ways to respond to them.

Sometimes, that means supporting patients in accessing existing services, says Kelly Tourere, Beacon’s strategic coordinator.

As the mother of an adult daughter with a learning disability, Tourere’s experienced first-hand how difficult it can be to stay on top of the paperwork and other requirements for accessing and maintaining assistance programs. “They get assistance, but they also need that support,” Tourere says of clients who may find themselves in similar situations to her daughter’s. “The nuts and bolts and the logistics of that assistance are not always that easy to navigate.”

After five years of collecting data and connecting former hospital patients, as well as other people in need, with resources, Beacon continues to increase the scope of services it provides both locally and statewide.

The nonprofit is already working with Ochsner hospitals to provide peer support to patients who come to the hospital with opioid-related issues. Through the Ally program, people who have experience with addiction themselves are sent out to talk to patients while they are still at the hospital, to provide them with pointers on where to go next. This fall, Beacon is launching the program at Our Lady of Lourdes hospitals in the region.

Having Beacon to serve as a centralized hub to connect hospitals, patients and social services is unprecedented, says Decell, who has worked for Ochsner for 12 years and hasn’t heard of anything similar from colleagues across the state. “We didn’t have anything like that, prior to our partnership with them,” she says. “It’s something unique to this area.”

That might change soon, however, as the nonprofit continues broadening its geographic scope as well. Beacon now provides services in Monroe and, earlier this year, opened an office in Lake Charles.

For clients like Mitchell, the results are life-changing.

“I just can’t say what it’s like to be inside and not in my truck,” Mitchell says on a recent afternoon, as an unexpected storm sends thick raindrops bouncing off the bed of the pickup parked outside. “I’m so grateful.”