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
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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
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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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San Francisco General Hospital and
Trauma Center
 SFGH BY THE NUMBERS ‘10-’11- con’t
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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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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
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Demographics
 Gender:
 85%
males
15% female
 Race / Ethnicity:
 59%
African American
 31% Euro-American
 03% Native American
 07% Latino
 Homeless
 Uninsured
82%
48%
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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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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
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Eligibility and Referrals
 5 or more visits to SFGH MER in past 12
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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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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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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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Research Design
Randomized Trial
252 high users of SFGH ED were:
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Stratified by ED utilization into LoHi
and HiHi users
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Randomized to CM (2/3) or UC (1/3)
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Followed every 6 months for 24 months
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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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Results of Randomized Treatment
Study: ED Use
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Mean # of Emergency Dept visits
8
CM-HiHi
CM-LoHi
UC-HiHi
UC-LoHi
7
6
5
4
3
2
1
0
months 1-6
months 7-12
months 13-18
months 19-24
Time Period
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Results of Randomized Treatment
Study: IP Medical Days
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CM-HiHi
CM-LoHi
UC-HiHi
UC-LoHi
Mean # of Inpatient Days
8
7
6
5
4
3
2
1
0
months 1-6
months 7-12
months 13-18
months 19-24
Time Period
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Results of Randomized Treatment
Study: Problem Alcohol Use
% clients with problem alcohol use
60%
CM-HiHi
CM-LoHi
UC-HiHi
UC-LoHi
50%
40%
30%
20%
10%
0%
6 month
12 month
18 month
24 month
Interview
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Results of Randomized Treatment
Study: Homelessness
80
% of clients homeless
70
CM-HiHi
CM-LoHi
UC-HiHi
UC-LoHi
60
50
40
30
20
10
0
month 6
month 12
month 18
month 24
Interview
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Results of Randomized Treatment
Study: SSI / SSDI
70%
% clients with SSI income
60%
50%
40%
30%
CM-HiHi
CM-LoHi
UC-HiHi
UC-LoHi
20%
10%
0%
6 month
12 month
18 month
24 month
Interview
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Results of Randomized Treatment
Study: Health Insurance
70%
% of clients with insurance
60%
50%
40%
30%
CM-HiHi
CM-LoHi
UC-HiHi
UC-LoHi
20%
10%
0%
6 month
12 month
18 month
24 month
Interview
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Who are we talking about
 “Lily”
 “El Diablo”
 “Jake”
 “Sadie”
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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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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
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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
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Questions?
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