SFGH- Department of Psychiatry Emergency Department Case Management Program (EDCM) September 24, 2012

1. SFGH- Department of PsychiatryEmergency Department Case Management Program (EDCM)September 24, 2012 Kathy O’Brien, LCSW Program Coordinator 415-206-5071 kathy.o’brien@sfdph.org Presented at WSHA Safe Table - ER is for Emergencies

2. 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 Presented at WSHA Safe Table - ER is for Emergencies

3. 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 Presented at WSHA Safe Table - ER is for Emergencies

4. 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 Presented at WSHA Safe Table - ER is for Emergencies

5. Demographics • Gender: • 85% males 15% female • Race / Ethnicity: • 59% African American • 31% Euro-American • 03% Native American • 07% Latino • Homeless 82% • Uninsured 48% Presented at WSHA Safe Table - ER is for Emergencies

6. 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 Presented at WSHA Safe Table - ER is for Emergencies

7. 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 Presented at WSHA Safe Table - ER is for Emergencies

8. 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 Presented at WSHA Safe Table - ER is for Emergencies

9. 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 Presented at WSHA Safe Table - ER is for Emergencies

10. 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 Presented at WSHA Safe Table - ER is for Emergencies

11. 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 Presented at WSHA Safe Table - ER is for Emergencies

12. 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 Presented at WSHA Safe Table - ER is for Emergencies

13. Results of Randomized Treatment Study: ED Use Presented at WSHA Safe Table - ER is for Emergencies

14. Results of Randomized Treatment Study: IP Medical Days Presented at WSHA Safe Table - ER is for Emergencies

15. Results of Randomized Treatment Study: Problem Alcohol Use Presented at WSHA Safe Table - ER is for Emergencies

16. Results of Randomized Treatment Study: Homelessness Presented at WSHA Safe Table - ER is for Emergencies

17. Results of Randomized Treatment Study: SSI / SSDI Presented at WSHA Safe Table - ER is for Emergencies

18. Results of Randomized Treatment Study: Health Insurance Presented at WSHA Safe Table - ER is for Emergencies

19. Who are we talking about • “Lily” • “El Diablo” • “Jake” • “Sadie” Presented at WSHA Safe Table - ER is for Emergencies

20. 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 Presented at WSHA Safe Table - ER is for Emergencies

21. 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 Presented at WSHA Safe Table - ER is for Emergencies

22. 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 Presented at WSHA Safe Table - ER is for Emergencies

23. Questions?