Canai,
This is why I liked the program in NM. They realized that the majority of people being repeatedly admitted to the hospital were also the same folks who used the ER on a repeated basis. Most had mental health conditions with medical issues, many were from the homeless population, either had a substance abuse problem or mental health problem. Once identified,they were encouraged to be part of the program where a nurse practioner does home visits on a daily or weekly basis. The program does a lot of advocacy, problem solving, from helping homeless to find housing, get regular meals, insure they get their medication, to any other need that they have that affects their health. If they find that the person is a veteran, they help them get hooked in with using VA services and benifits. With this program, a decrease in hospitalization, a big decrease in the "frequent flyers" at the ER with over all improvement in health for the patient has occurred and a saving in time and resources.