SF Department of Public Health
Coordinated Care Management System
Maria X Martinez
Sharing information
on our shared clients:
Is the juice worth the
squeeze?
Situation
Overwhelming need in Managed Care to identify, understand,
and find high-risk individuals
Silo systems are linear. People come in, get served one at a
time, get diagnosed, data stored
Need to coordinate and track high-risk individuals, measure
their system usage and system’s effectiveness, have markers
Providers unaware of others working with patients and
duplicate, miss, confuse care
Money spent on homeless system of care is reported, but
unduplicated homeless individuals unknown
Maria X Martinez, SF DPH, 415-554-2877,
maria.x.martinez@sfdph.org
2
MIS Challenges
Data segregated by specialty silos, funding silos, vendor silos
IT priorities are to implement large systems to maximize
revenue, serve as clinical chart, & meet meaningful use criteria
Getting systems to talk to each other is expensive
Manual integration of datasets for analyses is very timeconsuming and one-shot…not sustainable
Jumping on and off of multiple systems requires too much time,
too complicated in the provider setting
Maria X Martinez, SF DPH, 415-554-2877,
maria.x.martinez@sfdph.org
3
Approach to Solution
Integrate datasets and create composite picture of each unique
patient.
Identify transactional datasets that collect bio-psycho-social
information about high-risk patients
Develop design team (Clinical, Epidemiology, IT, and
Management) to determine what data are relevant.
Set-up transfer of data to warehouse server; once there,
program system to match and merges
Maria X Martinez, SF DPH, 415-554-2877,
maria.x.martinez@sfdph.org
4
Purpose of Data Integration
Aim is not to replace source databases, to bill,
or serve as an EMR
Goal is to tell the patient’s story, identify the
Care Coordinating Team, facilitate timely
communication, and offer “actionable”
information
Maria X Martinez, SF DPH, 415-554-2877,
maria.x.martinez@sfdph.org
5
Coordinated Case Management System
Begun in 2005, CCMS has
grown to include
bio-psycho-social histories of
over 600,000 adult
high-risk / high-cost patients.
Maria X Martinez, SF DPH, 415-554-2877,
maria.x.martinez@sfdph.org
6
Maria X Martinez, SF DPH, 415-554-2877,
maria.x.martinez@sfdph.org
7
Maria X Martinez, SF DPH, 415-554-2877,
maria.x.martinez@sfdph.org
8
How data from
CCMS are being
used to
understand and
improve clinical
care and systems
of care.
Maria X Martinez, SF DPH, 415-554-2877,
maria.x.martinez@sfdph.org
9
CCMS by Domains
Physical
Health
Mental
Health
Substance
Use
Living
Situation
Finances
Legal
Safety
Skills
Support
Meaningful Role
Maria X Martinez, SF DPH, 415-554-2877,
maria.x.martinez@sfdph.org
10
Home Page
Maria X Martinez, SF DPH, 415-554-2877,
maria.x.martinez@sfdph.org
11
Community Care Plan
Maria X Martinez, SF DPH, 415-554-2877,
maria.x.martinez@sfdph.org
12
Death Registry (State of California)
Maria X Martinez, SF DPH, 415-554-2877,
maria.x.martinez@sfdph.org
13
Health Service Summary
Maria X Martinez, SF DPH, 415-554-2877,
maria.x.martinez@sfdph.org
14
Health Services Detail
Maria X Martinez, SF DPH, 415-554-2877,
maria.x.martinez@sfdph.org
15
Understanding Populations Served
• Identify risk factors and acuity based upon all
health and human service systems
• Profile utilization of urgent/emergent services
• Determine span of time with homeless history
• Compare programs, clinics, panels,
populations
• Determine overlapping/shared populations
maria.x.martinez@sfdph.org, 415-554-2877
16
EMS High Users
EMS High Users are defined as anyone transported
four or more times in any one month. Two-thirds
appear acutely, one-third are chronic.
Misuse of crisis services results in fragmented care for
high-risk patients and cost overruns for an already
over-taxed system; as well as delayed response times
for others in need of ambulance and emergency
department services.
Maria X Martinez, SF DPH, 415-554-2877,
maria.x.martinez@sfdph.org
17
Maria X Martinez, SF DPH, 415-554-2877,
maria.x.martinez@sfdph.org
18
Maria X Martinez, SF DPH, 415-554-2877,
maria.x.martinez@sfdph.org
19
Maria X Martinez, SF DPH, 415-554-2877,
maria.x.martinez@sfdph.org
20
Maria X Martinez, SF DPH, 415-554-2877,
maria.x.martinez@sfdph.org
21
High Users of Multiple Systems (HUMS)
A small percentage of clients, despite assertive case
management and repeated efforts at stabilization in the
community, are failing to recover.
Present with transitory cognitive impairments and lengthy
histories of self-neglect and assaults, necessitating higher
levels of care in multiple systems. In lieu of routine
community care, they repeatedly use urgent / emergent
services.
Their confluence of co-morbid disorders results in extremely
high rates of premature mortality &high costs to the system.
Maria X Martinez, SF DPH, 415-554-2877,
maria.x.martinez@sfdph.org
22
Urgent/Emergent Care in SFDPH
Medical System
• EMS transports
• ED medical
• Inpatient – 24hr
• Medical Respite
(hospital offset)
• Urgent care clinics at
TWHC, hospital
*Programs in red are the only ones studied
in other communities.
Psychiatric Sytem
• PES, Dore St (PES offset)
• Psych Inpatient – 24hr
• Acute Diversion Units
(hospital offset) – 24hr
• Crisis clinics at Westside,
Mobile Crisis
Substance Abuse System
• Sobering Center
• Res Medical Detox –
24hr
• Res Social Detox – 24hr
Maria X Martinez, SF DPH, 415-554-2877,
maria.x.martinez@sfdph.org
23
Hi Users All
Hi Users Prim
FY1314 Users of Urgent/Emergent (U/E) Services Systems: DPH- Care: 25+ SFGH
Risk Factors wide Top 1% Med Inpt Days
Total U/E Costs
Average Cost per User
% of Total U/E Costs
% of Total U/E Users
Total U/E Users
Age over 60
Homeless last 12 months
Jail Health History During FY
Deaths (per Death Registry)
MEDICAL U/E System Users (during FY)
MENTAL HEALTH U/E System Users (during FY)
SUBSTANCE ABUSE U/E System Users (during FY)
Medical Elixhauser Conditions
Psych Elixhauser Conditions
Substance Abuse Elixhauser Conditions
Tri-Morbid Elishauser Conditions
Over 10 Elixhauser Conditions
$ 27,330,489 $ 15,716,314
$
70,804 $
73,786
16.8%
9.7%
1.0%
0.5%
386
213
16.6%
25.4%
72.5%
33.8%
21.2%
7.0%
5.7%
0.9%
91.2%
100.0%
50.0%
8.5%
53.4%
18.3%
90.9%
99.1%
85.2%
66.7%
90.2%
70.4%
73.3%
51.6%
30.3%
46.5%
Maria X Martinez, SF DPH, 415-554-2877,
maria.x.martinez@sfdph.org
24
Keys
1. Generate shared vision and leadership
…this is going to take time.
2. Iron-out privacy and security issues for
sharing data.
3. Assure you have IT bandwidth.
4. Engage the provider community…what
do they need at the moment of truth to
improve the patient experience? What
do they need to manage their panels or
caseloads better?
5. Engage the epidemiology
community…what data do they need to
evaluate outcomes?
6. Develop protocols for how providers are
expected to use integrated data.
Maria X Martinez, SF DPH, 415-554-2877,
maria.x.martinez@sfdph.org
25
Thoughts?
Questions?
Maria X Martinez, SF DPH, 415-554-2877,
maria.x.martinez@sfdph.org
26
San Francisco Department of Public Health
Maria X Martinez
Office of the Director of Health
415-554-2877
maria.x.martinez@sfdph.org
Maria X Martinez, SF DPH, 415-554-2877,
maria.x.martinez@sfdph.org
27