PROCESS Case Study: Ms. S & Social Medicine 1 2/15/2020 Main - PDF document

2/15/2020 Agenda • Case study • Process ‘Meeting People Where They're At': Social Medicine in the Emergency Department • People • Patients Jenna Bilinski RN MBA Jack Chase MD FAAFP FHM Hemal Kanzaria MD MSc Director, Kaizen Promotion Office Associate Professor Associate Professor • Q & A Zuckerberg San Francisco General Dept of Family and Community Dept of Emergency Medicine Hospital Medicine UCSF UCSF PROCESS Case Study: Ms. S & Social Medicine 1

2/15/2020 Main Goals and Targets Social Medicine in the ED •  short-stay hospitalizations driven by social needs by 50% PDSA Start (from 500 to 250/year) by December 2018 Pharmacy Meds in Hand Program 8/17 •  multi-disciplinary teamwork in ED to coordinate care Care Plan Documentation in ED Information Exchange (EDIE) 10/17 Transitions to Hummingbird, transitional housing, respite 10/17 ED MD-SW Multi-Disciplinary Rounds 11/17 Transitions PT/OT Engagement of ED Utilization Management RNs 11/17 MD SW Patient ED Patient Care Coordinator 1/18 Social Medicine Consult Service 1/18 Pharm UM Case Conferences for Frequent Users 3/18 SW Provider Social Needs Screening Tool (in EPIC) 6/18 Bedside Patient Social Med EMS-6 + Base Station Collaboration 7/18 RN MD PEOPLE 2

2/15/2020 SOCIAL ZSFG ED Immediate post ‐ ADMISSION Visit discharge period Ambulatory care SOCIAL Acute Inpatient Admission READMISSION Community ‐ based care (independent housing, RCF/E, respite, SRO, shelter) or residential care (SNF, LTC, LTAC) ED Social Medicine Team Caregivers and family Residential Community City Social Social Care Shelter Service Services Transitional system Agencies Care PT/OT Linkage SW Insurance/ Emergency Payors Housing ED MD/NP CC RN Eligibilty Bedside RN Caregivers Pharmacist and family Patient SUD Treatment Patient Care Substance Other (ambulatory Use Coordinator Social Med MD clinicians and Linkage residential) 3

2/15/2020 PATIENTS Transformative Stories • Finally getting off the BART • Can you help me with my W2? • Going home to Sicily 4

2/15/2020 Patient Outcomes Systemic Outcomes • Increased access to acute care beds and resources for the hospital’s catchment population (1/8 of SF population • Over 3,500 patients served seek care at ZSFG) • One or more PDSA initiatives to address homelessness, mental • Estimated cost savings of $1.8 million (from aversion of ~500 non ‐ acute admissions) illness, substance use, food insecurity, inadequate insurance coverage, broken linkage to care • Contribution to successful achievement of MediCal PRIME (pay for performance) goal readmission reduction (~$500K/year) • Aversion of 500+ admissions and readmissions driven by • Increased understanding and advocacy to address social determinants of health health ‐ related social needs • Income disparities • Housing shortage • Limited access to/availability of social services • Structural barriers to self ‐ care • Institutionalized racism • Social stigma 5

2/15/2020 Most of all, thanks to our patients QUESTIONS & ANSWERS (P)FUNDING • Potential mix of hospital support, payor ‐ based initiatives, private & philanthropic giving • Who are your stakeholders? • What outcomes do they find valuable/meaningful? • How to craft a mix of data and stories to convey the impact? 6