1 Jan Eldred Karen W. Linkins Lisa Mangiante December 10, 2008

2 Overview of the Initiative Five year project funded by The California Endowment and the California HealthCare Foundation, based at Corporation for Supportive Housing California Program The issue – emergency rooms are inundated with large numbers of patients, many of whom have complex, unmet needs not effectively dealt with in acute care settings Create a more responsive system of care that proactively – Addresses patients’ need and produces better health outcomes – Frees up emergency department resources for acute medical crises

3 Who Are Frequent Users? 65% chronic illness (diabetes, cardiovascular disease, chronic pain, cirrhosis & other liver disease, asthma & other respiratory disease, seizures, Hepatitis C, and HIV) 53% substance use issues (alcohol, methamphetamines, crack/cocaine, heroin, prescription drugs) 45% homeless, living on the streets 32% mental illness (Axis I and II) 36% have 3+ of these presenting conditions

4 The Challenge Disproportionate use by small number of patients Most use is avoidable – 8.9 ED visits each annually, with average annual charges of $13,000 per patient – 1.3 hospital admissions annually – 5.8 inpatient days each, with average annual charges of $45,000 per patient Episodic, hospital-based care doesn’t effectively meet the multiple, complex needs

5 The Models 6 counties, 6 programs (partnerships of hospitals, health/human service, housing, behavioral health, criminal justice) 5 intensive case management, 1 brief peer intervention 3 hospital-based, 3 community-based Various team compositions ranging from peer counselors and paraprofessionals to multidisciplinary teams – one with social workers and nurses and the ability to bill for direct services

6 Frequent User Case Management Key elements Connect patients to both medical and non-medical services (e.g., primary care, mental health, drug and alcohol treatment, housing, transportation) Intensive individual support, especially initially Coordination of care Effective linkages between case managers and ED

7 Policy Impact Increased awareness of frequent users and commitment to address high cost, ineffective utilization patterns Other initiatives in place that affect some frequent users – Coverage Initiative—expands healthcare to some uninsured (10 counties) – Mental Health Services Act — provides funding to county mental health departments for services to people w/ serious and persistent mental illness – Coordinated Care Management Program — pilot to reimburse for services to low income people with medical illness and serious and persistent mental illness in some counties SB 1738 (2008) Passed both houses with bi-partisan support but vetoed by Governor (prefers “statewide solution”) Victories: universal agreement on the approach, belief in the data, and Administration and stakeholder commitment to work together next year

8 Local Accomplishments Most Initiative programs self-sustaining Broader adoption of case management & multidisciplinary care Increased collaboration to improve service delivery: – frequent user programs and supportive housing – FQHCs and hospitals – health and mental health agencies, health agencies and jails Increased focus on benefits advocacy Collaborative planning of community initiatives for overlapping populations: – Medical respite for homeless patients – Coverage Initiative for uninsured Californians – 10 year plans to end homelessness

9 Outcomes: Connections to Housing, Health, and Income Benefits Clients homeless at enrollment: – 34% connected to permanent housing Clients connected to health benefits: – 68% Medicaid applications approved Clients connected to SSI: – 53% SSI applications approved

10 Outcomes: Hospital Utilization & Charges Per Person 1 Year PRE 2 Years POST % DIFFERENCE Average ED Visits % decrease Average ED Charges$11,388$4,69759% decrease Inpatient Admissions % decrease Avg. Inpatient Days % decrease Avg. Inpatient Charges $46,826$14,68469% decrease

11 More information For more information about the Initiative or to download the Frequent Users of Health Services Initiative: Final Evaluation Report, visit: