1. SFGH- Department of Psychiatry Emergency Department Case Management Program (EDCM) September 24, 2012 Kathy O’Brien, LCSW Program Coordinator 415-206-5071 kathy.o’brien@sfdph.org 1 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 2 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 3 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 4 Presented at WSHA Safe Table - ER is for Emergencies

5. Demographics  Gender:  85% males15% female  Race / Ethnicity:  59% African American  31% Euro-American  03% Native American  07% Latino  Homeless 82%  Uninsured 48% 5 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 6 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 7 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 8 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 9 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 10 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 11 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 12 Presented at WSHA Safe Table - ER is for Emergencies

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

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

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

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

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

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

19. Who are we talking about  “Lily”  “El Diablo”  “Jake”  “Sadie” 19 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 20 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 21 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 22 Presented at WSHA Safe Table - ER is for Emergencies

23. Questions? 23