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

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

Apr 21, 2023 18 likes •78 views

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

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2/15/2020 1 ‘Meeting People Where They're At': Social Medicine in the Emergency Department

Jenna Bilinski RN MBA Director, Kaizen Promotion Office Zuckerberg San Francisco General Hospital Jack Chase MD FAAFP FHM Associate Professor Dept of Family and Community Medicine UCSF Hemal Kanzaria MD MSc Associate Professor Dept of Emergency Medicine UCSF

Agenda

  • Case study
  • Process
  • People
  • Patients
  • Q & A

Case Study: Ms. S & Social Medicine

PROCESS

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2/15/2020 2

Main Goals and Targets

  •  short-stay hospitalizations driven by social needs by 50%

(from 500 to 250/year) by December 2018

  •  multi-disciplinary teamwork in ED to coordinate care

Patient SW Provider

Patient

Bedside RN Pharm MD Transitions PT/OT SW UM Social Med MD

Social Medicine in the ED

PDSA Start

Pharmacy Meds in Hand Program 8/17 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 Engagement of ED Utilization Management RNs 11/17 ED Patient Care Coordinator 1/18 Social Medicine Consult Service 1/18 Case Conferences for Frequent Users 3/18 Social Needs Screening Tool (in EPIC) 6/18 EMS-6 + Base Station Collaboration 7/18

PEOPLE

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2/15/2020 3

ZSFG ED Visit Immediate post‐ discharge period

Community‐based care (independent housing, RCF/E, respite, SRO, shelter) or residential care (SNF, LTC, LTAC)

Acute Inpatient Admission SOCIAL READMISSION Ambulatory care SOCIAL ADMISSION

ED Social Medicine Team

Patient Social Med MD Pharmacist ED MD/NP Transitional Care Linkage PT/OT SW CC RN Bedside RN Substance Use Linkage Patient Care Coordinator Community Social Services Residential Care City Social Service Agencies SUD Treatment (ambulatory and residential) Insurance/ Payors Eligibilty Shelter system Emergency Housing Other clinicians Caregivers and family Caregivers and family

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2/15/2020 4

PATIENTS

Transformative Stories

  • Finally getting off the

BART

  • Can you help me with

my W2?

  • Going home to Sicily
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2/15/2020 5

Patient Outcomes

  • Over 3,500 patients served
  • One or more PDSA initiatives to address homelessness, mental

illness, substance use, food insecurity, inadequate insurance coverage, broken linkage to care

  • Aversion of 500+ admissions and readmissions driven by

health‐related social needs

Systemic Outcomes

  • Increased access to acute care beds and resources for the hospital’s catchment population (1/8 of SF population

seek care at ZSFG)

  • Estimated cost savings of $1.8 million (from aversion of ~500 non‐acute admissions)
  • Contribution to successful achievement of MediCal PRIME (pay for performance) goal readmission reduction

(~$500K/year)

  • Increased understanding and advocacy to address social determinants of health
  • Income disparities
  • Housing shortage
  • Limited access to/availability of social services
  • Structural barriers to self‐care
  • Institutionalized racism
  • Social stigma
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2/15/2020 6

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?