Costs of Care.

It was his third visit to the emergency room in three days. The staff immediately recognized him. In the past year, he visited the ER over 100 times. That’s twice a week, every week. The ambulance services also knew him well. Good Samaritans would call 911 about a man who was lying in the gutter. Ambulance workers found him on the streets, barely conscious, and reeking of alcohol.

His liver was rotting from the incessant flow of liquor. As a result, fluid that his body could not absorb pooled in his belly. Doctors used long needles to drain it, liter by liter. He spent days in the detoxification unit. Nurses regularly hovered over him, watching for tremors that could quickly overflow into seizures.

Though he had returned years ago from the war, his mind was still overseas. Crowds made him uncomfortable, visions of mangled bodies invaded his thoughts, and guilt overwhelmed his conscience. A half-pint of whiskey helped him forget all of that. A few tall cans of beer dulled the pain in his belly; three or four more helped him ignore the strangers who looked at him with disgust. Finally, a pint of vodka put him to sleep at night. Alcohol was his constant companion, the only one who understood, the only one who brought him comfort.

That comfort never lasted. Only after the alcohol had washed out was he aware that he was killing himself. In the hospital bed, he was contrite and swore that he would never drink again.

With a pocket stuffed with prescriptions—this one is to prevent the fluid from collecting in your belly, this one is to keep toxins out of your blood, this one is to decrease craving for alcohol—he wandered out of the hospital with only a referral to the homeless shelter. Where else could he go? There he learned to use his shoes as a pillow so no one would steal them, though sleep eluded him because of the crowded and noisy conditions. People bullied him for money and food. Shelter workers had little power to protect him. Fed up with the constant chaos there, he fled back to the streets and sought refuge in windowless alleys. Police officers gave him tickets, then arrested him, for trespassing and sleeping outside. Youths, seeking entertainment, urinated on him or tried to set him on fire.

Burdened with this additional stress, he believed that liquor was his only savior.

His unpaid hospital bills—fees for ambulances, emergency room visits, medical procedures, nursing care, medications, lab tests, meals—came to hundreds of thousands of dollars. Everyone knew that the costs of his care would only increase if his cycles in and out of the hospital continued. Something had to change.

So, instead of sending him to the shelter after another admission for alcohol detoxification, the hospital referred him to a supportive residence. He now had an austere room to himself. A dedicated group of people worked with him so that he could get better. They were invested in keeping him indoors, out of trouble, and away from alcohol. If he did leave to drink, he was nonetheless welcome back inside. These caseworkers talked with him about his drinking and his health. They encouraged him to take care of himself. People believed that the costs of this intervention would be less than the costs to society otherwise.

Though it took time for him to settle in, he eventually drank less alcohol. He returned nightly to the residence and avoided the police patrols. He started visiting his physicians at their clinics regularly. No one needed to call 911 for him anymore and, as a result, his hospital visits decreased significantly. Though he still avoided people and crowds, he began to smile. So did everyone else.