Letter 3.

Dear Mr. WholePersonCare, 

You were the example that I shared with all of my colleagues who were evaluating this Medicaid Waiver in Los Angeles County called Whole Person Care.  It is for patients just like you— individuals who are “high-risk” for healthcare and have issues with mental heath, judicial issues involved, substance abuse, complex medical issues, homelessness, and complicated pregnancy.  You qualified for the Whole Person Care programs because you fulfilled 4 out of the 6 categories.  However, when talking to you I don’t know if you felt you were “high-risk” for anything.  You see in healthcare, high-risk means lots of things but ultimately your circumstances drive up the cost of care (like dollars and cents).  Improving “value” for you in healthcare means improving your outcomes and reducing your costs.  But what does that mean for you?  What health out comes are important to you?  What does cost matter if you don’t actually pay anything out-of-pocket? 

When we met, your demeanor was like others who I cared for who had been to jail before.  You seemed to be going through the motions; I could sense that you were certain of the steps ahead and you just needed to get passed my medical evaluation.  I couldn’t tell if my many questions annoyed you or if it surprised you. Your chart had pages of intake and discharge notes that described your IV drug use, schizophrenia and homelessness but didn’t explain your story.  At 43 years old, somehow Twin Towers Correctional Facility had become your second home. You were in and out of this place about every other week.  After combing through old notes to more recent notes, I read that on your most recent release from jail, 72 hours before meeting me, you were linked into the Whole Person Care program.  Someone scheduled 4 back-to-back appointments for you, from 10am to 4pm in different parts of Los Angeles, “to get you plugged in” to resources to help you with your substance abuse, mental health, and to get housing.  When you nonchalantly told me you went and got high after your release, I was not surprised.  However, the idea that anyone thought it was a good idea to schedule 4 appointments for you (or anyone else) in one day that were in all parts of Los Angeles County was surprising. 

In talking to you, you shared that for over 20 years you lived on the streets and used drugs; you mostly stayed in an encampment on Skid Row.  You explained that the drugs you use help you to cope with the voices you heard and keep you up at night to protect yourself from the harm of others on the streets.  You had developed a routine over the course of this time, picked up several drug charges, and now were on parole.  You don’t have the means to fulfill the requirements for parole so when the police come to your encampment to “clean up”; when they run your name you always get picked up for a parole violation.  Your story is like many others who keep the revolving doors of the jail in constant motion.  Three days ago, when you were released from jail at 1a, I get that the last thing on your mind was making it to your 4 Whole Person Care appointments.  Even if you wanted to change your circumstances, the stars that have to align to undo your normal are unimaginable.  On paper the Whole Person Care program, sounded like the magic bullet for folks like you and I wanted so badly for it to work.  But realistically, it will never work because it fails at meeting you (a whole person) where you are in your life.  Instead it asks you to make drastic changes to conform to what society has deemed as “acceptable”. 

Before you walked out of my exam room I said, “a lot of people are investing in you.”  I deserved the look of who cares that you shot at me.  But what I meant to say was that— I am fighting for you. My worry is that healthcare will give up on you and the large financial investments to address the circumstances that contribute to your “high-risks”. They won’t get the return on investment they were expecting, even though they didn’t design a program that would work for you, so they will move on.  I want so badly for you to live the life that you want to live while still being treated like a human being that is heard, seen, respected, and valued.  The jail is not that place, so how can we prevent you from coming back here? 

With the utmost respect,

Dr. A