SFGH- Department of Psychiatry Emergency Department Case Management Program (EDCM) September 24,...

SFGH- Department of PsychiatryEmergency Department Case

Management Program (EDCM)September 24, 2012

Kathy O’Brien, LCSWProgram Coordinator415-206-5071kathy.o’[email protected]

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Presented at WSHA Safe Table - ER is for Emergencies

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

1993-1994Collaboration between Dept of Psychiatry & Dept of MedicineChart review:

202 pts with 12 or more visits out of 49,4990.0041 % 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 82%Uninsured 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 servicesCrisis InterventionGroup and Individual CounselingMedical Assessment and CarePsychiatric Assessment and CareAssertive OutreachSocialization opportunitiesCoordinated 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

0

1

2

3

4

5

6

7

8

9

months 1-6 months 7-12 months 13-18 months 19-24Time Period

Mea

n #

of E

mer

genc

y D

ept v

isits

CM-HiHi

CM-LoHi

UC-HiHi

UC-LoHi

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Results of Randomized Treatment Study: IP Medical Days

0

1

2

3

4

5

6

7

8

9

months 1-6 months 7-12 months 13-18 months 19-24Time Period

Mea

n #

of In

patie

nt D

ays

CM-HiHi

CM-LoHi

UC-HiHi

UC-LoHi

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Results of Randomized Treatment Study: Problem Alcohol Use

0%

10%

20%

30%

40%

50%

60%

6 month 12 month 18 month 24 month

Interview

% c

lient

s w

ith p

robl

em a

lcoh

ol u

se CM-HiHi

CM-LoHi

UC-HiHi

UC-LoHi

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Results of Randomized Treatment Study: Homelessness

0

10

20

30

40

50

60

70

80

month 6 month 12 month 18 month 24

Interview

% o

f clie

nts

hom

eles

s

CM-HiHi

CM-LoHi

UC-HiHi

UC-LoHi

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Results of Randomized Treatment Study: SSI / SSDI

0%

10%

20%

30%

40%

50%

60%

70%


Interview

% c

lient

s w

ith S

SI i

ncom

e

CM-HiHi

CM-LoHi

UC-HiHi

UC-LoHi

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Results of Randomized Treatment Study: Health Insurance

0%

10%

20%

30%

40%

50%

60%

70%


Interview

% o

f clie

nts

with

insu

ranc

e

CM-HiHi

CM-LoHi

UC-HiHi

UC-LoHi

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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 progressGaps in serviceCreate ease of service can also raise

dependencyCM 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 teams22


Questions?

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SFGH- Department of Psychiatry Emergency Department Case Management Program (EDCM) September 24,...

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