Maria X Martinez

1. Urgent/Emergent Care and challenge 2. HUMS hypothesis 3. High users, multiple systems, and multiple

domains of disorders 4. Was FY 11-12 different? 5. IDS goals:

1. Targeted Street Outreach (EST)

2. Coordinated Case Management

3. Ambulatory Acuity Index

Medical System EMS transports ED medical Inpatient – 24hr Medical Respite (hospital

offset) Urgent care clinics at

TWHC, hospital

*Programs in red are the only ones studied

in other communities.

Psychiatric Sytem PES, Dore St (PES offset) Psych Inpatient – 24hr Adult Diversion Units

(hospital offset) – 24hr Crisis clinics at Westside,

Mobile Crisis

Substance Abuse System Sobering Center Res Medical Detox – 24hr Res Social Detox – 24hr

“High Users of Multiple Systems”

2007 study showed common features for high ambulance users: costly, multi-disordered, receiving care in multiple service agencies, unknown to individual systems, not sticking to any stabilizing services, and no care coordination.

HUMS Hypothesis: Coordinated care, supported by integrated data, can be an effective intervention to reduce costs and improve health outcomes.

$200 million annual urgent/emergent care estimated actual costs

50,000 – 55,000 unique individuals served annually

Top 1% of individuals account for 25% of costs.

Top 5% account for 55% of costs.

Summary of FY 10-11 # Patients Total Costs

% Total Costs

Ave Cost/Pt

Ave # Svcs

Top 1% 511 $49,793,566 25% $97,443 89

Next 2 - 5% 2,078 $58,527,401 30% $28,165 30

Remaining 95% 49,207 $88,187,508 45% $1,792 2.5

Totals 51,796 $196,508,475 100%

Number patients in each group, FY 10-11

Any 1 sys Any 2 sys All 3 sys totals Ave

Top 1% HU 199 175 137 511

Next 2-5% HU 1,009 800 269 2,078

Remaining 95% 46,344 2,654 209 49,207

Totals 47,552 3,629 615 51,796

HUMS 312

Average Urgent Care Cost per Individual FY 10-11

Any 1 sys Any 2 sys All 3 sys totals Ave

Top 1% HU $94,375 $98,148 $101,000 $97,443

Next 2 - 5% HU $27,311 $28,281 $31,028 $28,165

Remaining 95% $1,584 $4,913 $8,308 $1,792

Totals n/a n/a n/a

HUMS

FY 10-11 1 sys 2 sys 3 sys TotAve FY 11-12 1 sys 2 sys 3 sys TotAve

Top 1% 86 90 93 89 Top 1% 85 91 92 89

Next 2 - 5% 29 30 33 30 Next 2 - 5% 28 30 33 30

HUMS HUMS

No, average number services per urgent care patient is same.

FY 10-11 1 sys 2 sys 3 sys TotAve FY 11-12 1 sys 2 sys 3 sys TotAve

Top 1% HU

$94,375 $98,148 $101,000 $97,443 Top 1%

HU $104,365 $82,862 $57,488 $85,449

Next 2-5% HU

$27,311 $28,281 $31,028 $28,165 Next

2-5% HU $32,073 $21,367 $17,703 $26,498

HUMS HUMS

Yes, average cost per patient decreased for multi-system users, but increased for single system users.

Ambulatory Acuity Index Targeted Outreach Coordinated Case Management

Multiple Systems

1 system 2 systems 3 systems

SA Psy Med SA-Med SA-Psy Psy-Med Tri Totals

Top 1% HU - 56 143 44 6 125 137 511

Multi-disorders measured by Elixhauser Co-morbidity Index

0 Domains*

Diagnosis in 1 Domain

Co-Morbidity Diagnosis

Tri-Morbid

No Elix SA Psy Med SA-

Med SA-Psy Psy-Med Totals

Top 1% HU 12 5 8 52 81 63 58 232 511

* 0 Domains usually means the patient received urgent care services for acute, resolving condition; not chronic, progressive condition

30 diagnostic measurements add together to form final score.

Even a single positive response predicts early mortality if untreated.

All conditions are progressive without treatment.

Most conditions are chronic. They can be ameliorated and stabilized with treatment.

Some conditions are acute. They can be cured with treatment.

Circulatory System Cardiac Arrhythmias Valvular Disease Congestive Heart Failure Hypertension, Uncomplic. Hypertension, Complic. Peripheral Vascular Dis. Pulmonary Circulation Dis.

Digestive System Liver Disease Peptic Ulcer Disease, Excl

Bleeding

Endocrine System Diabetes, Uncomplicated Diabetes, Complicated Obesity Weight Loss Hypothyroidism

GenitoUrinary System Renal Failure

MusculoSkeletal System Rheumatic Arthritis /

Collagen Vascular Disease

Hematology System Deficiency Anemia Blood Loss Anemia Coagulopathy Fluid and Electrolyte

Disorders

Neurological System Paralysis Other Neurological

Disorders

Respiratory System Chronic Pulmonary Disease

Cancer Solid Tumor w/o Metastasis Metastatic Cancer Lymphoma

Immune System AIDS/HIV

Psychiatric Disorders Psychoses Depression

Substance Use Disorders Alcohol Abuse Drug Abuse

SFHOT Engagement Specialist Team

Targeted street outreach with the goal of more effectively engaging and placing HUMS into care (warm handoffs and follow-up)

24-hr schedule

Covers grid based upon CCMS knowledge of ambulance pickup histories

Responds to 311, police, EMS for street intervention

Transportation to & from urgent/emergent facilities

Current: HUMS Clinical Case Conference – monthly

EST Planned: Central call-in line for EDs to consult with EST and

RNs at Sobering Center (use of CCMS)

Addition of electronic case coordination tools including provider communication and oversight of “community care plan”

EST assist in finding patients who were engaged with case managers but have been “lost to follow-up”

HUMS + conditions are useful way to monitor high cost / high risk patients

HUMS method helps plan interventions to improve health outcomes and reduce costs

EST and Care Coordination changing interactions with HUMS patients

Further interventions and grant applications are planned

Spotlight may be reducing costs already