San Francisco - Kathy O`Brian
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Transcript San Francisco - Kathy O`Brian
SFGH- Department of Psychiatry
Emergency Department Case
Management Program (EDCM)
September 24, 2012
Kathy O’Brien, LCSW
Program Coordinator
415-206-5071
kathy.o’[email protected]
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San Francisco General Hospital and
Trauma Center
San Francisco General Hospital and Trauma Center is the sole
provider of trauma and psychiatric emergency services for the
City and County of San Francisco. A comprehensive medical
center, SFGH serves some 100,000 patients per year and
provides 20 percent of the city’s inpatient care.
SFGH BY THE NUMBERS ‘10-’11
598 licensed beds
102,000 patients treated
20% of all inpatient care in San Francisco
1,170 babies born
63,000 Emergency visits (medical & psych)
22,000 Urgent Care visits
3,900 Trauma activations
30% of all ambulances come here
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San Francisco General Hospital and
Trauma Center
SFGH BY THE NUMBERS ‘10-’11- con’t
550,000 outpatient visits
Approximately 2,600 City and 1,600 UCSF
Employees (FTEs)
32% of all UCSF resident training
$92.3 million in charity care provided in
FY2008—75% of all charity care provided in SF
Provides 93% of the inpatient care for
Healthy San Francisco enrollees
1 of 13 Emergency medicine residencies in CA
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Start Up of Program
1993-1994
Collaboration between Dept of Psychiatry &
Dept of Medicine
Chart review:
202 pts with 12 or more visits out of 49,499
0.0041 % yet 11 times more likely to use
MER
1995
Approved by Health Commission / Dept. of
Public Health
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Demographics
Gender:
85%
males
15% female
Race / Ethnicity:
59%
African American
31% Euro-American
03% Native American
07% Latino
Homeless
Uninsured
82%
48%
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EDCM Team
5 Social Work Case Managers
1 Primary Care Physician .50
1 Nurse Practitioner .80
1 Psychiatrist .25
1 Pharmacist .10
1 Social Work Supervisor and Screener
Program Coordinator
Administrative Assistant
SW Intern
Peer Specialist
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Services
Case Management / Brokerage services
Crisis Intervention
Group and Individual Counseling
Medical Assessment and Care
Psychiatric Assessment and Care
Assertive Outreach
Socialization opportunities
Coordinated Voc Rehab Opportunities
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Eligibility and Referrals
5 or more visits to SFGH MER in past 12
months or HUMS client
18 years or older
San Francisco resident
Not enrolled in duplicative CM program
Voluntary nature of services
Screening and pending status
Primary sources of referrals
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Eligibility and Referrals
Referrals are from :
Medical ED
IP Social Workers
DPH HUMS project
Dept. of Psychiatry
Community agencies
Collaboration with Health Plans
Collaboration with COPC Care teams
SF Private non-profit hospitals
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Outcomes Studies
1995-1996 Convenience sample of 174
patients resulted in study of 53 case
managed people
Lowered ED costs
Lowered IP costs
Decreased rates of homelessness, substance
abuse
Improved linkages to primary care
Net cost savings
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Research Design
Randomized Trial
252 high users of SFGH ED were:
Stratified by ED utilization into LoHi
and HiHi users
Randomized to CM (2/3) or UC (1/3)
Followed every 6 months for 24 months
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Research Design
Randomized Trial
84% of the 167 randomized to CM enrolled
with EDCM
No differences in terms of age, gender or
ethnicity between those who enrolled or not
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Results of Randomized Treatment
Study: ED Use
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Mean # of Emergency Dept visits
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CM-HiHi
CM-LoHi
UC-HiHi
UC-LoHi
7
6
5
4
3
2
1
0
months 1-6
months 7-12
months 13-18
months 19-24
Time Period
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Results of Randomized Treatment
Study: IP Medical Days
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CM-HiHi
CM-LoHi
UC-HiHi
UC-LoHi
Mean # of Inpatient Days
8
7
6
5
4
3
2
1
0
months 1-6
months 7-12
months 13-18
months 19-24
Time Period
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Results of Randomized Treatment
Study: Problem Alcohol Use
% clients with problem alcohol use
60%
CM-HiHi
CM-LoHi
UC-HiHi
UC-LoHi
50%
40%
30%
20%
10%
0%
6 month
12 month
18 month
24 month
Interview
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Results of Randomized Treatment
Study: Homelessness
80
% of clients homeless
70
CM-HiHi
CM-LoHi
UC-HiHi
UC-LoHi
60
50
40
30
20
10
0
month 6
month 12
month 18
month 24
Interview
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Results of Randomized Treatment
Study: SSI / SSDI
70%
% clients with SSI income
60%
50%
40%
30%
CM-HiHi
CM-LoHi
UC-HiHi
UC-LoHi
20%
10%
0%
6 month
12 month
18 month
24 month
Interview
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Results of Randomized Treatment
Study: Health Insurance
70%
% of clients with insurance
60%
50%
40%
30%
CM-HiHi
CM-LoHi
UC-HiHi
UC-LoHi
20%
10%
0%
6 month
12 month
18 month
24 month
Interview
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Who are we talking about
“Lily”
“El Diablo”
“Jake”
“Sadie”
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Nature of Case Management
Outreach and engagement
Clinical nature of the work
Considerations for staff mix
Appreciate the complexity of patient life
Linkage (more than a call and referral slip)
Nature & receptivity of non-MER services
What we’re expecting patients to do
Change what may “work” already for them
Navigate complex support systems
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Transition and termination
“CM for life?”
“When is enough, enough?”
Mutual goals and review of progress
Gaps in service
Create ease of service can also raise
dependency
CM own reluctance to close case
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Other SF Initiatives
DPH-Focus on High Users of Multiple
Systems (HUMS)
DPH- Housing and Urban Health
Housing first model
Eligibility criteria
Other housing options (respite to permanent)
DPH- Integrated Delivery System
2011-2012 planning process
Areas for change implementation
DPH- Clinic based care management teams
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Questions?
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