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Treating the ‘throw-away’ members of society

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Chris Ruge checks on patients at a Las Vegas mobile home park. Ruge heads a team that works with chronically ill Medicaid patients with the goal of improving care and preventing costly hospital visits. (Eddie Moore/Albuquerque Journal)

Chris Ruge checks on patients at a Las Vegas mobile home park. Ruge heads a team that works with chronically ill Medicaid patients with the goal of improving care and preventing costly hospital visits. (Eddie Moore/Albuquerque Journal)

Copyright © 2014 Albuquerque Journal

LAS VEGAS, N.M. – Anthony Lewis came here, like hundreds of others, as a patient of the New Mexico Behavioral Health Institute and today lives in one of the estimated two dozen boarding homes that house former residents of the state’s hospital for people with mental illness.

Lewis, 27, who has been diagnosed with schizophrenia, was in crisis when he left his native Artesia.

“It happened when I was having delusions,” Lewis said in an interview at the Loving Care boarding house in Las Vegas.

“I thought Jesus was trying to talk to me alone,” he said. “I hit my mom in the name of Jesus. Jesus doesn’t tell you to do things like that. If you think Jesus is telling you to do something, call your mom and ask her.”

An Eddy County magistrate in 2012 dismissed a criminal charge against Lewis of battery against a household member. He is scheduled to stand trial in July on a felony charge of battery on a police officer stemming from the same incident in March 2012.

Ruge, right, a nurse practitioner, jokes with his patient, Anthony Lewis, 27, during a visit to the Las Vegas boarding house where Lewis lives. Ruge has removed Lewis from two other boarding houses in response to reports of drug use in those facilities. (Eddie Moore/Albuquerque Journal)

Ruge, right, a nurse practitioner, jokes with his patient, Anthony Lewis, 27, during a visit to the Las Vegas boarding house where Lewis lives. Ruge has removed Lewis from two other boarding houses in response to reports of drug use in those facilities. (Eddie Moore/Albuquerque Journal)

But Lewis also has some new and valuable allies in his corner.

Chris Ruge, a Las Vegas nurse practitioner, in November enrolled Lewis in a University of New Mexico program, called ECHO Care, that targets severely ill, and very expensive, Medicaid patients for intensive, personalized care.

The three-year pilot program, funded by a $6 million grant from the federal Centers for Medicare and Medicaid, is intended to improve care for patients with complex illnesses and to save money by preventing costly hospital visits.

Officials estimate that just 5 percent of New Mexico’s estimated 632,000 Medicaid patients account for about half the state’s $4 billion annual Medicaid costs. Medicaid is a state- and federally-funded insurance program for the poor.

Ruge, a clinician at El Centro Family Health in Las Vegas, heads one of six ECHO Care teams in Las Vegas, Albuquerque, Santa Fe and Las Cruces.

Many of the sickest Medicaid patients suffer from a complex stew of problems, including mental illness, alcohol and drug addiction, and chronic illnesses, said Ruge, who has enrolled 50 patients in the program since September.

Las Vegas is unique because the state mental hospital is located here.

“We have hundreds if not thousands of people who have been essentially dumped here by cities and counties and their families at the state hospital,” he said. “The message is, whoever sent them doesn’t really want them to come back.”

Chris Ruge, right, a family nurse practitioner, visits with his patient Anthony Lewis at the boarding house where he lives in Las Vegas, N.M., on May 22, 2014. (Eddie Moore/Albuquerque Journal)

Chris Ruge, right, a family nurse practitioner, visits with his patient Anthony Lewis at the boarding house where he lives in Las Vegas, N.M., on May 22, 2014. (Eddie Moore/Albuquerque Journal)

An industry of boarding houses, which range widely in quality, has grown up here to provide housing to former patients such as Lewis, Ruge said.

“These are basically the throw-away members of our society so they don’t really have an advocate,” Ruge said. Many wind up on the streets.

Providing a safe living environment is often job No. 1 for Ruge and Rebecca Sena, the team’s full-time community health worker. Ruge has removed Lewis from two boarding homes since November after Ruge heard reports of drug use in those facilities.

Conditions in the boarding homes can be deadly. On Oct. 24, two former New Mexico Behavioral Health Institute patients, Cochise Bayhan, 56, and Alex Montoya, 61, died of carbon monoxide poisoning in a backyard shed converted for use as a boarding home.

The property’s owners, Jose Encinias, 47, and his wife Denise A. Encinias, 41, pleaded not guilty last month to two counts each of neglect of a resident resulting in death.

Ruge and Sena frequently visit patients in their homes. Sena routinely picks up food from a Las Vegas food bank and delivers it to patients. She also provides them with clothing vouchers and makes sure their utilities are working.

Ruge said he must earn the trust of patients who too often have been ignored and mistreated by the health care system.

“There are a number of people who have a really deep-seated distrust of the health care system because of past experience,” said Ruge, who for 10 years provided intensive outpatient care for HIV/AIDS patients in Massachusetts before he began work with El Centro in 2008.

Paula Jaramillo, 26, listens to nurse practitioner Chris Ruge during an exam at El Centro Family Health Clinic in Las Vegas. Jaramillo enrolled in a program that provides her with intensive medical care after she was hospitalized in April with two minor strokes. (Eddie Moore/Albuquerque Journal)

Paula Jaramillo, 26, listens to nurse practitioner Chris Ruge during an exam at El Centro Family Health Clinic in Las Vegas. Jaramillo enrolled in a program that provides her with intensive medical care after she was hospitalized in April with two minor strokes. (Eddie Moore/Albuquerque Journal)

Ruge enrolled Paula Jaramillo, 26, in April after she was hospitalized with dangerously low blood sugar levels, resulting in two mild strokes.

“I was losing weight very fast,” said Jaramillo, who dropped from 250 pounds to 138 in five years. “I was throwing up every day and just feeling so tired.”

Jaramillo’s main connection to the health care system was the local emergency room.

“All the doctors told me there was nothing wrong with me,” she said. “I was getting the run-around from everybody. I just really got turned off by the whole doctor thing.”

Medicaid patients are eligible for ECHO Care if they have been hospitalized at least twice in the past year or have made three emergency room visits in the past six months. They also must have poorly controlled chronic illnesses.

Jaramillo was diagnosed two years ago with a rare genetic illness called Cowden syndrome, which causes many dangerous problems, including nodular growths that can become cancerous. The disorder also has destroyed her teeth, which has made it all but impossible for her to eat solid food.

Each Monday at noon, Ruge and other ECHO Care team leaders join a teleconference, called the “complex care clinic,” that gives them access to a dozen UNM specialists in a variety of fields.

The clinic is based on the UNM Project ECHO model, a web-based system formed in 2003 by UNM physician Dr. Sanjeev Arora to help him treat hepatitis C patients statewide with the help of primary care clinicians.

Project ECHO has since been expanded to 20 illnesses, including HIV/AIDS, diabetes, substance abuse, mental illness, chronic pain, high-risk pregnancy and others.

ECHO Care, which began enrolling patients in September, marks the first time the model has been used to treat patients with multiple conditions, said Dr. Miriam Komaromy, associate director of Project ECHO.

ECHO Care today enrolls about 250 patients statewide. Plans call for each team to enroll 125 patients under the care of five health professionals at each site, she said.

At a teleconference clinic last month, Ruge described Jaramillo’s case to the team of specialists, who recommended a diet that included protein shakes, soups, fruits and other soft foods.

“With kind of a simple solution, we’ve been able to avoid the low sugars,” Ruge said. “So we haven’t been back to the ER again.”

Jaramillo credits the diet with stabilizing her blood sugar levels and keeping her out of the hospital. “That’s what has helped me more than anything,” she said.

Chris Ruge, a nurse practitioner, standing, examines his patient Jerry Romero, 57, during a visit to Romero’s home. Romero is one of 50 Las Vegas patients enrolled in a program intended to prevent ER visits and hospital admissions. (Eddie Moore/Albuquerque Journal)

Chris Ruge, a nurse practitioner, standing, examines his patient Jerry Romero, 57, during a visit to Romero’s home. Romero is one of 50 Las Vegas patients enrolled in a program intended to prevent ER visits and hospital admissions. (Eddie Moore/Albuquerque Journal)

Attention to diet also is a key issue in Ruge’s care of Jerry Romero, 57, who suffers liver disease, jaundice and a severely swollen stomach as a result of chronic alcoholism.

On a recent trip to Romero’s trailer in Las Vegas, Ruge asked the retired firefighter to bring out foods he had eaten recently, including a package of bologna.

“Even two slices of bologna in a day is approaching your salt limit,” Ruge told Romero after examining the nutritional information on the package. “The problem with processed meat is they are filled with sodium. That’s going to make your swelling worse.”

The swelling, which Ruge calls “the baby,” sent Romero to the hospital last year, leading to his referral to the ECHO Care program.

Ruge also warned Romero to cut out the cigarettes. “If we can’t eliminate the smoking, I don’t think your liver will get better.”

When Ruge asked about alcohol use, Romero responded that he hasn’t had a drink in 14 months.

“That’s one reason you’re still alive,” Ruge said. “I just want to improve your chances.”

Chris Ruge, a family nurse practitioner, helps Katherine Macomber with an issue involving a meter to check her blood sugar at her home in Las Vegas, N.M., on May 22, 2014. (Eddie Moore/Albuquerque Journal)

Chris Ruge, a family nurse practitioner, helps Katherine Macomber with an issue involving a meter to check her blood sugar at her home in Las Vegas, N.M., on May 22, 2014. (Eddie Moore/Albuquerque Journal)

Katherine Macomber, 57, was admitted to a hospital five times in 2013 for conditions ranging from a severe beating to substance abuse problems.

In a recent visit to her Las Vegas apartment, Ruge spent 30 minutes inspecting Macomber’s 14 medications for diabetes, high blood pressure, anemia, anxiety, depression, seizures and other conditions.

When Macomber enrolled in the program earlier this year, “her meds were a jumble,” Ruge said. “She was really unable to supervise her own medications.”

Ruge often calls Wal-Mart pharmacy himself and delivers them to her home.

“It really takes a lot of pressure off me,” Macomber said. “I thought house calls went out in the 1900s.”

Strict attention to medication is likely the reason Macomber has had only a single admission to a hospital this year, he said.

“Probably 80 percent of the work we do is making sure the system works for our patients,” Ruge said.

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