Diagnosis Homeless: Emergency department “super-utilizers” and urban poverty in Atlanta, Georgia Public
Salhi, Bisan (Spring 2018)
Published
Abstract
A 2014 analysis by the Agency for Health Research and Quality estimated that the 1% of American patients account for nearly a quarter of health care expenditures (https://meps.ahrq.gov/data_files/publications/st448/stat448.shtml). These patients, referred to as “frequent fliers” or, more politely, “super-utilizers,” have been the focus of a growing number of health care interventions designed to meet their needs, reduce their healthcare utilization, and curb rising costs in the process. Using a variety of ethnographic data—participant observation, unstructured and semi-structured interviews, chart reviews—this dissertation examines patients who have visited the Grady Memorial Hospital Emergency Department in Atlanta, Georgia, 10 or more times in a 30-day period and the healthcare providers tasked with caring for them. Nearly all patients who were labeled super-utilizers in this study were homeless. Therefore, a focus on super-utilizers and urban poverty constitutes the bulk of this dissertation. Specifically, I turn my attention to the ways in Atlanta is a city where vast wealth and abject poverty exist side by side, and worlds apart. For people left behind by Atlanta’s uneven development, Grady remains one of the last remaining safety nets for the poor. As such, the hospital picks up where Atlanta leaves off, providing shelter, safety, and life-saving services when the city simply turned a blind eye and comforted itself with its images of urban revitalization. This dissertation therefore challenges the assumption that hospitals are places where hospitals are simply institutions for healthcare delivery. Instead, I argue, they are urban safety nets, forced to supplement the shortcomings of a receding social service infrastructure. Further, they are extensions of the social world and all of its stratifications and inequalities. Finally, this dissertation focuses on the ways in which marginalized people are maligned and labeled “frequent fliers” and “super-utilizers,” thereby detracting from their vulnerability and labeling them a drain on health care (and by extension societal) resources. An important contention in this dissertation is that it is inadequate—even misleading—to label individuals as “super-utilizers.” My research demonstrates that the “super-utilizer” is not a type of person, but that this category represents a time of extreme vulnerability in a person’s life. Moreover, this vulnerability is not an individual deviance or shortcoming, but a product of Atlanta’s uneven development that has seen hospitals turn into an omnibus service center warehousing and hiding the city’s marginalized populations from public view. Thus, the attribution of this label to individuals, and targeting them through well designed and well-intentioned interventions obscures the broader processes that are necessitate this behavior. More importantly, this attribution obscures the immense costs and injustices associated with a privatized healthcare system and enables the disenfranchisement of those most in need
Table of Contents
TABLE OF CONTENTS PART ONE: THE PROBLEM AND THE PROJECT CHAPTER ONE: INTRODUCTION 2 SAFETY NET OR SPECIALTY? 6
DEFINING DEVIANCE: WHAT IS A SUPER-UTILIZER? 12
A NOTE ON TERMINOLOGY 25
THE FIELD SITE: GRADY MEMORIAL HOSPITAL 27
OUTLINE OF THE DISSERTATION 30 CHAPTER TWO: METHODS 36 INTRODUCTION 36
LOCATION 38
INSTITUTIONAL REVIEW BOARD AND APPROVAL 39
PROCEDURE 40
STUDYING STAFF 41
IDENTIFYING SUPER-UTILIZERS 44
STUDYING SUPER-UTILIZERS 45
OTHER PATIENTS 50
ETHNOGRAPHIC DATA COLLECTION 50
CHART REVIEWS 55
TABLE 1: SUMMARY OF ETHNOGRAPHIC DATA 55
TABLE 2: DEMOGRAPHIC AND UTILIZATION CHARACTERISTICS OF 138 DEPARTMENT PATIENTS IDENTIFIED IN THIS STUDY56
ANONYMITY AND DATA PROTECTION 56
CONCLUSION 57 CHAPTER THREE: SUPER-UTILIZERS: A GENEALOGY 60 INTRODUCTION 60
THE GOMER PHENOMENON 64
WHAT’S IN A NAME? SUPER-UTILIZERS RECONSIDERED 78
CONCLUSION 93 PART TWO: HISTORY AND CONTEXT CHAPTER FOUR: GRADY BABY 96 INTRODUCTION 96 GRADY: A BRIEF HISTORY 101
SPACE, PRIDE, COMMUNITY 108
A SAFETY NET FOR ALL 123
CONCLUSION: RECONSIDERING THE HOSPITAL 134 CHAPTER FIVE: OF HOSPITALS AND ALMSHOUSES 137 INTRODUCTION: LUCY 137 FROM THE ALMSHOUSE TO THE HOSPITAL 146 MAGGIE 161 CONCLUSION: SUPER-UTILIZERS REVISITED 172 PART THREE: THE LIVES OF SUPER-UTILIZERS CHAPTER SIX: AN OVERVIEW OF HOMELESSNESS & EMERGENCY MEDICINE 175 WHAT IS HOMELESSNESS? 175
HOMELESS IN AMERICA 178
HOMELESS IN NEOLIBERALISM 191
“I’M NOT HOMELESS! I JUST DON’T HAVE ANYWHERE TO STAY.” 200
HOMELESS IN THE EMERGENCY DEPARTMENT 204
CONCLUSION 213
CHAPTER SEVEN: KINSHIP, WEAK TIES, AND THE URBAN POOR 215 INTRODUCTION: CLIVE 215
GETTING BY: RELATIONSHIPS, FRIENDS, AND KIN NETWORKS 221
THE LONERS 231
ANNIE 242
ALONE IN ATLANTA 248
CONCLUSION: DO THESE COUNT AS TIES? 252
CHAPTER EIGHT: WHAT HAPPENS TO SUPER-UTILIZERS? 254 AN UPDATE ON SUPER-UTILIZERS IN THIS DISSERTATION 254 CHAPTER NINE: CONCLUSION AND DISCUSSION 260 INTRODUCTION 260
CONTRIBUTIONS OF THIS THESIS 266
CONSEQUENCES AND NEXT STEPS 272 APPENDIX A: MAP OF THE GRADY ED DURING CONSTRUCTION 276 BIBLIOGRAPHY 277
About this Dissertation
| School | |
|---|---|
| Department | |
| Degree | |
| Submission | |
| Language |
|
| Research Field | |
| Mot-clé | |
| Committee Chair / Thesis Advisor | |
| Committee Members |
Primary PDF
| Thumbnail | Title | Date Uploaded | Actions |
|---|---|---|---|
|
|
Diagnosis Homeless: Emergency department “super-utilizers” and urban poverty in Atlanta, Georgia () | 2018-04-05 14:46:58 -0400 |
|
Supplemental Files
| Thumbnail | Title | Date Uploaded | Actions |
|---|