Doctors at the UC San Diego Medical Center emergency room in Hillcrest discharged the city’s most prolific user of 911 services at 5:58 on a recent evening, another chapter in a maddening game of treat and release.

For the 242nd time in three years, they stabilized the 66-year-old chronic alcoholic who had arrived by ambulance. They found a sweet spot between his drunken helplessness and the delirium tremens that would rack his body if he dried out too long.

Then they abided his rights and sent him on his way, despite an estimated $537,000 worth of emergency medical services incurred over the years for this lone, wheelchair-bound homeless man.

“The ER has become a dumping ground,” said Anne Jensen, coordinator of San Diego’s Resource Access Program, a group of six community paramedics who focus on an estimated 1,236 frequent users of 911 citywide.

“By law, the ambulance has to take him” to the hospital, Jensen said.

Three years ago, The San Diego Union-Tribune and the California HealthCare Foundation Center for Health Reporting spotlighted the moral, medical and financial challenges involved in the treatment of frequent users of the emergency system. The five-part report, “Health Care 911,” helped the city start key programs, including the establishment of the community paramedic team.

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Today, frequent users still account for an outsized 11.6 percent of all city ambulance calls. But that’s a marked improvement from the 17.3 percent of calls they rang up three years ago.

Since their program launched a year ago, the community paramedics have obtained more than 650 waivers from these individuals — mostly homeless men and women. The forms allow them and other caregivers to place the patients in detox facilities and provide case management that includes supervised housing.

View the photo gallery: San Diego's Top 911 User

The goal is to save lives — and in the process save money by reducing frequent users’ drain on the 911 system. It can cost tens of thousands of dollars per year to house, feed and medically rehabilitate a frequent user, but that’s still far cheaper than a protracted cycle of paramedic pick-ups and emergency room care.

By definition, frequent users are people who request 911 assistance at least six times a year.

“Super users,” as Jensen calls them, tap the system at least 20 times a year.

The priority for the community paramedics has been “mega users,” who activate 911 at least 50 times a year.

“Our goal was not to start by cherry-picking the easy patients. It was to start with the very worst,” said Dr. Jim Dunford, medical director for San Diego and chief architect of the city’s efforts to curb serial use of 911.

View the Video Dr. Jim Dunford

Dunford’s goal now is to unite disparate entities so they will share information about patients’ cases and invest in certain social-services programs at an unprecedented level. The players include health providers for the poor, the St. Vincent de Paul Village in the city’s East Village area, the nonprofit Downtown San Diego Partnership and local hospital emergency rooms.

A powerful foundation for this endeavor is Street Sense, a one-of-a-kind iPad program used by the community paramedics. The software tracks frequent users’ 911 calls in real time, identifies where these patients can likely be found and offers known medical and social service histories for those people.

Despite these efforts, the alpha user of them all has consistently offered the community paramedics two statements when approached with a waiver:

“Leave me alone.”

“I want to die on the street.”

Visit 243

After his release from the emergency room in a wheelchair, the patient wheeled himself to a nearby bus stop in Hillcrest.

Surprisingly strong in the semi-sober state doctors had achieved, he spun himself up the vehicle’s ramp without the assistance he often requires. The bus churned toward the Gaslamp Quarter streets that serve as his home when he’s not on an ambulance gurney.

True to the behavior revealed by the Street Sense software, he got off the bus on Fifth Avenue, a few blocks before the trolley station on C Street.

His drink of choice is vodka, and along that stretch, drugstores sell bottles of it as cheap as $2.59.

The man found a spot to drink, unseen to passers-by.

His next stop was outside the House of Blues during a sold-out show, where youths and young adults congregated like peacocks. He stationed his wheelchair next to the doorman’s podium, and at times looked up to the gatekeeper as if wishing to speak.

But he was not acknowledged and could form no words, this man whose name is not shared publicly by paramedics and doctors because it’s unclear whether he has the mental capacity to consent.

As hip-hop started to pulsate from within the venue, he acted out what looked like a reverie to younger days. Following the commands of a disc jockey, he raised his hands in the air, limply out of time with the beat.

Shortly after a bicycle-mounted security guard with the Downtown San Diego Partnership noticed him, he dropped his hands to wheelchair rims and inched away.

The slope of the avenue gently landed him astride an apartment building where his head stooped to examine a plastic bottle cradled in his lap. But he no longer had the inclination to raise it to his lips.

Then, in a spurt of energy, the man wheeled himself across Broadway. Cars came to a halt.

Subway sandwich shop worker Christian Magna talks to San Diego's top user of 911 while in a Subway sandwich shop on Fifth Avenue. Hayne Palmour IV

The homeless man didn’t possess the energy to spin up the sidewalk ramp. He was stuck in a teeter-totter motion until a sign twirler interrupted his toil for a local taco shop and pushed the wheelchair the last few feet.

The homeless man navigated the sidewalk in a lazy zigzag until Joseph Durish, 41, a fellow homeless person, bent down to ask him a few questions. Durish thought he heard the man say he was hungry, so he pushed him briskly toward the doors of a Subway sandwich shop.

But in the shop, the man was again speechless and did not roll up to the counter. Patrons moved around him, unsure if he was in line.

Sandwich maker Christian Magana, 20, finally took it upon himself to wheel the man out.

“Sometimes he’ll have a sandwich here on Saturdays,” Magana said. “But right now he was trying to sleep, and we can’t let him do that here.”

The Gaslamp crowd began to thicken, and people started to dodge the homeless man with growing notice and unease.

Then the same bicycle-mounted security guard at the House of Blues, who later said he was “not comfortable” giving his name to a reporter, approached him.

“I’m going to keep you rolling, buddy,” the guard said as he pushed the man toward the curb.

“I don’t care,” the man in the wheelchair let out — his first coherent words of the night.

“You don’t want to go to the hospital?” the guard suggested.

“I don’t care,” the man repeated in halting syllables.

The guard pulled out his cellphone and dialed the inevitable: 911.

All six members of the community paramedic team were off duty.

A city ambulance and fire crew arrived within five minutes. Firefighter-paramedic Tre Broughton asked protocol questions to determine if the man was ill or incoherent, both of which required an ER transport.

“I need some help,” the man muttered.

“We all know him,” Broughton said, as crew members shut the ambulance doors with the man and wheelchair secured within.

At 9:07 p.m., three hours and nine minutes after his release from the emergency room, the man was on his way back for visit 243.

“We’re going to come up with a game plan for him,” Dunford vowed the next day.

Patient privacy

Shortly after that night in the Gaslamp, the list-topping frequent user was arrested on an indecent-exposure charge. He had become incontinent, soiled himself and was trying to clean up in public.

A routine screening at the county jail showed he had tuberculosis, so he was transferred, still in custody, to UC San Diego in Hillcrest for more medical tests.

“Their routine over there is to just sober him up and release him, but this time they actually admitted him,” said San Diego police Officer John Liening of the department’s Serial Inebriate Program, which tries to channel people who are frequently arrested for public drunkenness into recovery services.

The additional screening revealed advanced heart failure, liver problems and other ailments, said Dunford, who was briefed on the patient’s condition.

“He’ll die on the street if released again,” Dunford said.

Paramedic Tre Broughton talks to San Diego's top user of 911after a private security guard for the Downtown San Diego Partnership called for an ambulance to pick up the homeless wheel chaired man on Fifth Avenue. Hayne Palmour IV

So Liening persuaded the District Attorney’s Office and the courts to release the man from custody so he could be taken to a supervised nursing home, where substance-abuse services would be offered.

The patient would be kept in observation at the hospital while follow-up tests were run, and then be taken to a local nursing home where space was found.

But sometime over Labor Day weekend, the hospital put the man back in his wheelchair and released him.

Michelle Brubaker, a spokeswoman for the UC San Diego Health System, said the hospital couldn't give information on the patient because he declined to sign a consent form.

"Generally speaking, programs like this that involve diverse community resources have been shown to have significant benefits to recipients, but they require the willing participation of all," she said.

Liening, who has known the man for a decade — when he first appeared on the streets and could still walk — said: “The lack of coordination and information sharing with these cases is just incredible.”

Dunford said it doesn’t have to be that way.

San Diego has received $2.5 million in grants to build a Community Information Exchange that would provide digital health information on all frequent users.

The Street Sense program used by community paramedics is the principal data feed. Social-work case managers at St. Vincent de Paul also have agreed to plug their computer systems into the exchange, so they can prioritize the needs of new clients and see if previous clients have fallen into old behavioral patterns.

The local PATH program — People Assisting the Homeless — also has agreed to join the exchange.

Liening’s program at the San Diego Police Department wants to participate as well, but to what extent remains unresolved.

And the Downtown San Diego Partnership wants at least limited involvement.

The sticky issue of patient privacy laws is addressed through an agreement that establishes a shared understanding of the federal Health Insurance Portability and Accountability Act, Dunford said.

So far, however, local hospitals have not made any commitments to the exchange. They already have built a system called the Health Information Exchange using federal grants, and Dunford believes it’s imperative that the two systems merge.

“Put these two together, and now the health and social worlds are combined,” said Dunford, who has testified before Congress on the need to unite such information.

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Next steps

Meanwhile, a report released in April said Project 25, a program at St. Vincent de Paul Village that seeks to improve frequent users’ lives by providing housing and coordinated care, saved San Diego taxpayers $3.7 million in ambulance, jail and social-service costs related to those individuals.

That was a combined figure for 2012-13, when St. Vincent took in 36 frequent users — not 25 as the program’s name implies.

The savings were realized even after accounting for the expense of housing, medical care, job placement and other services, according to the analysis, which was conducted by the Fermanian Business & Economic Institute at Point Loma Nazarene University.

Grants from the United Way initially funded Project 25. When that money ran out earlier this year, the program had to find long-term investors.

The city’s Medi-Cal Managed Care providers — Kaiser Permanente, Community Health Group, Molina Healthcare, Care1st Health Plan and the San Diego VA Healthcare System — have agreed to cover up to 40 percent of service costs for Project 25 clients.

The Affordable Care Act , also known as Obamacare, is part of the equation.

Because hospitals receive federal “disproportionate share” funds to care for low-income and other patients, the frequent-user turnstile at their emergency rooms helped some turn a profit. The Affordable Care Act has reversed that, with hospitals now penalized for readmissions as a quality-control incentive.

So managed-care providers see Project 25 as a good investment, a way to keep frequent users out of the hospital.

But instead of reaching out to the top 911 users in San Diego regardless of their insurance enrollment — the original strategy for Project 25 — the current approach is to target patients already in the managed-care plans.

Kaiser Permanente spokesman Rodger Dougherty said selection of Project 25 participants is evolving, and that existing participation in one of the health plans would no longer be a requirement going forward.

Dunford sees a larger picture: an unprecedented deal that has all medical insurers paying to house the homeless.

“Housing has become health care,” he said.

Gonzales is a senior writer for the California HealthCare Foundation Center for Health Reporting.