PHILADELPHIA - Not while he was in the ambulance - weakness, vomiting and the wooziness that accompanies a lack of insulin tend to crowd out any latent instinct for the ironic.
But by the time Frederick Pegues Jr. was resting in bed at Temple University Hospital, the irony struck him hard.
Here, he had just finished a month-long course in being a community health worker, sponsored by Temple University Hospital. He had learned how to help patients navigate a complicated health system. Yet he himself had not been able to get the help he needed.
Unwillingly, Pegues, 38, an unemployed and uninsured diabetic from North Philadelphia, had become Exhibit A for why people needed a community health worker. If a health worker had run interference for him to get the insulin he needed, he would not have been in the emergency room and he would not have ended up in the hospital.
"It did strike me as ironic," Pegues said. "All it would have taken was someone to speak on my behalf."
The idea of using lay people such as Pegues to help people in their own communities is nothing new. In countries where medical resources are scarce, community health workers are a necessary and accepted part of health care delivery, handling myriad nonmedical chores and specializing in health education.
In the United States, these health workers have been an idea whose time, over the decades, is always coming but yet to fully arrive. That is particularly the case in today's prevalent payment model, under which insurers generally reimburse doctors and hospitals based on services rendered, not services avoided.
The payment model, however, is changing, which is why Temple University, in partnership with other organizations, and Pegues' 25 fellow students see themselves on the cutting edge of an old idea made new by economics, governmental policies and the Affordable Care Act.
The economics are simple enough. Health costs keep rising. Part of the prescription for lowering them is better health. The other part is reducing waste.
Paula L. Stillman, vice president of health care services at Temple's hospital and the architect of the Community Health Worker training program, sees the program as a way to address both.
"We're in a transition phase," she said. "Today we get reimbursed by quantity. If we look into the future, we will be reimbursed by quality and controlling costs.
"The reimbursement system has not caught up with how health care will be delivered. When the reimbursement catches up, we want to be prepared."
The payment system is already starting to catch up.
Effective last week, hospitals' reimbursements from Medicare will be cut if patients are soon readmitted with the same condition. That provides a powerful push for hospitals to make sure discharged patients understand their medications and treatment plans, and have a doctor instead of showing up in the emergency room.
"I don't want someone to come into the very-expensive emergency room with a runny nose," Stillman said. "It's a totally useless use of the facility."
Typically, she said, community health workers will act as pleasant nags. Because they often live in the neighborhoods where they work, they may be more successful than medical professionals in linking patients with the right kind of care, or keeping them engaged in their treatment.
Whether any of this will work is an open question. Studies have been scattered, and most programs have not survived long enough to yield consistent long-term data.
Even in the short term, "the degree of success of your program will be correlated to the robustness of the infrastructure supporting these workers," said Michael Gibbons, associate director of the Johns Hopkins Institute of Urban Health in Baltimore. In other words, it's fine for workers to help patients access resources - if the resources exist.
Temple's training program, provided free to carefully selected participants, ended just after Labor Day. Class topics included cultural sensitivity, interviewing skills, availability of community resources and communication skills. Students learned a minimum of medicine - enough to know when to call a supervisor.
"We're not training mini-docs," Stillman said.
Area health insurers, who helped pay for the training, are also funding evaluation. "You have to show a return on investment," Stillman said.
Temple plans to hire several of the program's graduates, assigning two to emergency rooms. They will get a caseload of frequent patients who use the emergency room for nonemergency care. Two others will land at Temple primary-care practices that send patients to Temple's hospital. They will visit patients at home to follow up on issues.
Jill Foster, director of both the Center for the Urban Child and the Dorothy Mann Center for Pediatric and Adolescent HIV at St. Christopher's Hospital for Children, has used a health worker for years at the HIV center.
"It's a second pair of hands, a second pair of eyes, another brain to help problem-solve."
HealthPartners, which specializes in Medicaid health insurance for the poor, will pay for a health worker at Foster's Urban Child Center.
Foster wants the health worker to follow up on patients who miss appointments. Aside from health concerns, every no-show costs. Each no-show leaves a slot that could have been filled with a revenue-generating patient.
If Foster's community health worker can cut the no-show rate in half, it will more than cover community health worker's pay.
But it's not just the money.
"They don't tell us the obstacles - that they are imminently homeless or they have partner violence," Foster said. "They are afraid we'll look down on them."
Stillman and her partners in this venture - AFSCME District Council 1199C's Training and Upgrading Fund, the Center for Social Policy and Community Development at Temple University, and the Camden Area Health Education Center - have been setting up interviews to link the graduates with employers.
Two-thirds of the students are unemployed.
Tiffany Lovett, 34, has been out of work since June 2011. Lovett, who lives with her husband and two children in Germantown, thinks she understands the African-American community.
"It's a very fine line you walk. You have to know the pulse of the community to be able to help them," Lovett said. "But there are things you can't say until you've built up a relationship."
Lovett has conducted home visits in other jobs and already knows the safety rules her classmates were taught:
Choose a hard-backed chair so it's easier to make a quick escape. Don't sit with your back to the door, but also make sure nothing is between you and the door.
Pegues also feels a sense of mission. Helping him relate to his neighbors, he said, are his degree in psychology and his own ability to cope with a chronic condition, diabetes.
But even a disciplined approach to disease management can go wrong, which is why, on Sept. 13, Pegues found himself in the hospital, an unwilling example of the issues he hopes to fix.
Because he was in class Aug. 24, he asked his mother to go to a Philadelphia public health center to pick up his insulin. He should have gotten two vials. Instead, he received one, he said.
When he went to the health center to request the second vial, he was told he could not receive more until Sept. 17. His insulin ran out Sept. 7.
He tried to make do, but by Sept. 13, when he dragged himself to the clinic, he was weak and vomiting, his blood sugar so high that the clinic couldn't handle it. The hospital became a necessity.
Jobless, Pegues can't afford the bill, which will start at $4,500 for the overnight. Add doctors and tests, and the tab will rise. Now all that is Temple's cost to bear.
Stillman estimates that a community health worker will earn $35,000 a year including benefits. Had one been available to help Pegues, he might not have been hospitalized, and the $4,500 saved would have covered nearly seven weeks of the worker's pay. And that's not even addressing the state of Pegues' health.
"That's why this program is so important," Stillman said.