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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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Presented at WSHA Safe Table - ER is for Emergencies
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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Presented at WSHA Safe Table - ER is for Emergencies
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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Presented at WSHA Safe Table - ER is for Emergencies
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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Presented at WSHA Safe Table - ER is for Emergencies
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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Presented at WSHA Safe Table - ER is for Emergencies
Services
Case Management / Brokerage servicesCrisis InterventionGroup and Individual CounselingMedical Assessment and CarePsychiatric Assessment and CareAssertive OutreachSocialization opportunitiesCoordinated Voc Rehab Opportunities
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Presented at WSHA Safe Table - ER is for Emergencies
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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Presented at WSHA Safe Table - ER is for Emergencies
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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Presented at WSHA Safe Table - ER is for Emergencies
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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Presented at WSHA Safe Table - ER is for Emergencies
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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Presented at WSHA Safe Table - ER is for Emergencies
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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Presented at WSHA Safe Table - ER is for Emergencies
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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Presented at WSHA Safe Table - ER is for Emergencies
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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Presented at WSHA Safe Table - ER is for Emergencies
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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Presented at WSHA Safe Table - ER is for Emergencies
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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Presented at WSHA Safe Table - ER is for Emergencies
Results of Randomized Treatment Study: SSI / SSDI
0%
10%
20%
30%
40%
50%
60%
70%
6 month 12 month 18 month 24 month
Interview
% c
lient
s w
ith S
SI i
ncom
e
CM-HiHi
CM-LoHi
UC-HiHi
UC-LoHi
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Presented at WSHA Safe Table - ER is for Emergencies
Results of Randomized Treatment Study: Health Insurance
0%
10%
20%
30%
40%
50%
60%
70%
6 month 12 month 18 month 24 month
Interview
% o
f clie
nts
with
insu
ranc
e
CM-HiHi
CM-LoHi
UC-HiHi
UC-LoHi
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Presented at WSHA Safe Table - ER is for Emergencies
Who are we talking about
“Lily” “El Diablo” “Jake” “Sadie”
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Presented at WSHA Safe Table - ER is for Emergencies
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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Presented at WSHA Safe Table - ER is for Emergencies
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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Presented at WSHA Safe Table - ER is for Emergencies
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
Presented at WSHA Safe Table - ER is for Emergencies
Questions?
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