San Francisco Pilot Program Behavioral Health Focus David Serrano Sewell Hospital Council of Northern & Central California Abbie Yant Dignity Health
Convening for Change: Addressing San Francisco s Emergency Department Challenge Abbie Yant VP Mission, Advocacy and Community Health Services Saint Francis Memorial Hospital David Serrano Sewell Regional Vice President San Francisco Hospital Council of Northern and Central California December 6, 2017 Riverside Convention Center Riverside, CA
What should San Francisco focus on in 2017? Do something about ED strain
We CAN do better for patients
S.F. Emergency Physicians Association asked us Can we talk about ED issues?
ED Visits Continue to Increase
The Diversion Rates are Raising % of ED Capacity on Diversion and CAGR 26% + 30% 12% 13% 16% 7% 7% 2011 2012 2013 2014 2015 2016 YTD
High ED Utilization Impacts Many PATIENTS PAYORS (Employers, Taxpayers, Consumers) HOSPITALS OTHERS
Healthcare Leaders have made successful changes, like the Sobering Center A 2002 report led to the Center s creation Since July 2003, it has provided care for 14,000 individuals for a total of 48,000 encounters Successful alternate destination with data validated outcomes
Remember, we are acting together and speaking with one voice Right?
The City s Hospital CEOs took action by commissioning a report Protecting San Francisco Emergency Services: Diagnosing and Addressing the Challenges of San Francisco s EDs Drive a public policy agenda for change
EDs are a vital resource, particularly for the most vulnerable Patient Personas Diego Insured by employer Margaret Medi-Cal Enrollee Jinn Li Medicare Enrollee Harry Homeless, Addiction Issue Sam Struggling with mental illness Sofia Infant <1 year old Reason for Visit Injuries Pre-existing, previously undiagnosed or Multiple chronic illnesses, likely to result in being Untreated conditions, multiple non-clinical needs Behavioral disorders with frequent flare-ups Early childhood infections and complications unmanaged illness admitted Annual Visits Every 7 years Every other year Every other year Twice a year N/A Every other year For Every 100 Visits For Every 100 Hours 28 visits (~10 for injuries) 26 visits 21 visits \ Focus 8 visitsof recommendations / 7 visits 2 visits <28 hours < 24 hours < 27 hours < 13 hours < 19 hours < 2 hours
Conducting over 50 interviews with Experts Validated the Systemic and Structural Issues 10% of ED visits may be preventable through more proactive primary, chronic and mental health, and addressing social determinants of health 40% of ED visits may be avoidable if an appropriate, convenient, affordable alternative is offered Diversion (city average 26%), awareness of options, and transport availability may prevent optimal ED selection High occupancy in the ED may produce long wait times (30 min average) Lack of availability of inpatient (ZSFGH at 97%) or post-acute capacity can increase time in the ED Lack of follow-up can result in readmission Primary care is not very accessible, leaving patient health unmanaged until they need to use the ED Segments of population are just comfortable getting all care at an ED It is common for multiple hospitals to be on diversion Boarding is common in the ED due to delay in discharge to postacute or in-patient bed unavailability We do not have enough psych capacity in the city to move patients out of the ED For many Medi-Cal patients, we do not have the information to contact their PCP post-discharge
Compounding the issue are social challenges outside of the direct control of hospitals, such as substance abuse Alcohol-/Drug-Related Visits between ED and Sobering Center 23,644 23,361 22,687 25,256 23% 19% 18% 14% 100% 77% 81% 82% 86% 2011 2012 2013 2014 Sobering Center Visits Alcohol or Drug related ED visits
Sobering Center Arrivals 1,350 1,513 1,321 1,507 FY 12-13 FY 13-14 1,195 FY 14-15 867 622 465 350 409 457 355 531 457 398 ED via Van MAP Van EMS Ambulance Police Other
More patients are now being brought to ED by ambulances than before Percentage of ED Patients Arriving by Ambulance in 2015 25% 21% 24% 17% 37% 29% 21% 27% 7% CPMC- Davies CPMC- Pacific CPMC- St. Luke s Chinese Hospital Kaiser St. Francis St. Mary s UCSF ZSFGH
Of particular concern are so-called 5150 patients, who may be held for up to 72 hrs 5150 detentions per 1,000 population 12 +8% 10 8 6 4 2 0 FY 10-11 FY 11-12 FY 12-13 FY 13-14 Adult Child
While appropriate specialized sites to handle urgent and emergent psychiatric needs exist, they are also over capacity Psych Related ED visits 17,273 (7%) ED visits with mental disorder as principal diagnosis 245,111 (93%) ED visits with non-psych principal diagnosis FY14-15
Estimated Range of Capacity Gap in Psych Emergency Beds 35 15 8 hours 20 hours Estimated average length of stay
CEOs adopt key recommendations (December 2017) SUPPORT and EXPAND lower-acuity settings serving substance abuse-related/psychiatric needs ESTABLISH a Behavioral Health ED Task Force to evaluate how much and what type of additional lower-acuity capacity is needed EMPOWER the LEMSA to triage/transport patients to alternate destinations DIRECT the Post-Acute Care Collaborative to focus on programs that will speed the discharge/transition of patients INFORM key stakeholders on the findings
The Report influenced policy that led to results Public/Private partnership 56-bed unit at Saint Mary s Memorial Hospital to serve patients placed on various mental health conservatorships More Respite Beds at Hummingbird Navigation Center Optimizing Coordination of Care at LEMSA, now at DPH Launch two workgroups for 2018
POST-ACUTE CARE COLLABORATIVE Identified solutions to improve the availability and accessibility of post-acute care services for vulnerable populations and Medi-Cal beneficiaries Two sub-groups - Cognitively Impaired and Behaviorally Challenged Standardized Assessment Tool Citywide Roving Placement Team Increase Access to Supportive Living Alternatives
BEHAVIORAL HEALTH ED TASK FORCE Representation from City, ED physicians, BH and public health leaders to identify the type, quantity, location and funding of additional capacity needed to relieve the strain on the EDs Expand the capacity of lower acuity (acute and subacute) psychiatric facilities to relieve ED strain Increase treatment and care options in the community to reduce ED utilization Invest in systems improvements
The two workgroups found similarities in recommending System Level Changes and Individual Level Services
Lessons Learned Health Leaders are respected experts, but it is all about the Patients Convening stakeholders will build relationships Expert convening/facilitation matters Informed data makes for effective advocacy to policy makers Behavioral Health dominates, but so does discharge
Getting People Talking will Lead to Change
Questions?
Thank you David Serrano Sewell dserranosewell@calhospital.org Abbie Yant abbie.yant@dignityhealth.org 31