SLIDE 1
Next 30 Minutes
- Trends
- San Francisco
- Poverty as driver
- Where do we go from here?
SAN FRANCISCO HEALTH NETWORK A BROADER VIEW OF HEALTH Next 30 - - PowerPoint PPT Presentation
SAN FRANCISCO HEALTH NETWORK A BROADER VIEW OF HEALTH Next 30 - - PowerPoint PPT Presentation
SAN FRANCISCO HEALTH NETWORK A BROADER VIEW OF HEALTH Next 30 Minutes Trends San Francisco Poverty as driver Where do we go from here? Boston 1999 Current Trends Pubmed search for social determinants * * 1999 2013
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Boston 1999
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Current Trends
Pubmed search for “social determinants”
* *
1999 2013
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Healthcare and…
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San Francisco’s Track Record
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Director of Health
Finance Policy & Planning Zuckerberg San Francisco General Hospital
Laguna Honda Hospital Transitions and SF Behavioral Health Center Managed Care Ambulatory Care Primary Care Behavioral Health Jail Health Maternal, Child & Adolescent Health
Human Resources Information Technology Interdivisional Initiatives
Environmental Health Community Health Equity & Promotion Disease Prevention & Control
Public Health Emergency Preparedness & Response
Emergency Medical Services Office of Equity & Quality Office of Ops, Finance & Grants Mgmt. Center for Learning & Innovation
Applied Research, Community Health Epidemiology & Surveillance
Center for Public Health Research Bridge HIV
Security Communications Compliance & Privacy Affairs
Health Commission
Department of Public Health Organizational Chart
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SFHN MISSION
We provide high quality health care that enables all San Franciscans to live vibrant, healthy lives.
17 6 28 15 23 35 23 41 0% 20% 40% 60% 80% 100% SFHN San Francisco
race/ethnicity
Black Latino Asian White Other 59 18 10 15 10 7 0% 20% 40% 60% 80% 100% SFHN San Francisco
insurance
Medicaid Medicare Uninsured Other
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Social Medicine in the ED
AS: 89 year old woman originally from Australia. Living on BART, riding in her wheelchair all day, getting off at night to stay on street. Frequent incontinence, leading to 911 calls, escorted by BART police to local EDs. 60 ED visits at ZSFG alone in 12 months prior to intervention. February 2018 ED found to have pressure ulcers, had not bathed in months. Social medicine team elicited her priorities: hunger, painful bottom, concern for belongings being lost or stolen. Moved indoors that evening, sheltered since. Now clean, well nourished, healed skin. Has ID, applied for entitlements and insurance, looking into longer term residential housing.
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Social Medicine in the ED
- Many ZSFG ED patients have
high medical and social needs.
- ED volume and pace limit ability
to address complex needs, resulting in repeat ED visits or admissions for low medical/high social acuity.
- Multipronged initiative developed
to decrease short stay “social admissions” by 50% from 550 to 275 within one year.
PDSA Start
ED 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/NP-SW Multi-Disciplinary Rounds 11/17 Engagement of ED Utilization Management RN 11/17 ED Patient Care Coordinator 1/18 Social Medicine Consult Service 1/18 Social Needs Screening Tool 1/18
Slide adapted from Jack Chase and Hemal Kanzaria
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Social Medicine in the ED
Slide adapted from Jack Chase and Hemal Kanzaria
SFHN Transitions
Social Medicine MD
ED multidisciplinary team (MD/NP, PCC, SW, UM, Pharmacy)
Transitions team provides complex care management and residential care at shelters, SRO hotels and navigation centers. Social MD supports ED team with content expertise, incorporating biomedical, mental health, addiction medicine, and community-based social support elements into treatment plans. Patient care coordinator (PCC) serves as connector between patient, ED team and outpatient resources.
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Social Medicine in the ED
Slide courtesy of Jack Chase and Hemal Kanzaria
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Poverty as Driver
healthcare
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Historical Side Note
- Poverty thresholds developed in 1963.
- Based on Department of Agriculture’s
“thrifty food plan” which was “designed for temporary or emergency use when funds are low.”
- 1955 Household Food Consumption
Survey showed average family spent about 1/3 post-tax income on food.
If it is not possible to state unequivocally ‘how much is enough,’ it should be possible to assert with confidence how much, on average, is too little.
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Poverty: Prevalent, Deep
2016 Poverty Statistics Overall rate: 12.7% Twice FPL: 29.8% Half FPL: 5.8% Child rate: 18% Latino rate: 19% Black rate: 22% N American rate: 26.2%
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Poverty: Reified, Racialized
Slide adapted from Zea Malawa
”More than half the Negro population of San Francisco are located here, and it is considered a highly hazardous area.”
- 1937 Home Owner’s Loan Corporation
San Francisco elementary schools with lowest Academic Performance Index (API) scores
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How did we get from there to here?
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Capturing Complexity, Avoiding Reductionism
AS is an 89 female with
- Z59.0 homelessness
- Z59.5 extreme poverty
- Z59.7 insufficient social insurance
and welfare support
- Z99.3 dependence on wheelchair
- L89.3 pressure ulcer of buttock
- Z60.4 isolation, social
- N39.498 other specified urinary
incontinence
- Z59.4 lack of adequate food and
safe drinking water
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Follow the Money
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Healthcare is Complicit
Bradley EH, Taylor LA. The American Health Care Paradox: Why Spending More is Getting Us Less. 2013.
$59.9b $14.8b $1163.3b $54.9b
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It’s not really about us…
HOSPITALS
HEALTH PLANS
Green LA, Yawn BP, Lanier D, Dovey SM. The Ecology of Medical Care Revisited. NEJM 2001; 344(26): 2021-25.
PUBLIC HEALTH SELF MANAGEMENT “ALTERNATIVE” MEDICINE ”PRIMARY CARE” SPECIALTY REFERRALS HOSPITALIZATIONS ACADEMIC MEDICAL CENTER
PRIMARY CARE
PHARMA
DEVICES
HOUSING EDUCATION ECONOMIC DEVELOPMENT
SNFS
MENTAL HEALTH ADDICTION FOOD ARTS ENVIRONMENT DEFENSE
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A Path Forward
There are nearly 300,000 Medicaid recipients in the North Philadelphia zone… These families are more likely to experience deep poverty that affects not only their health but also their education, employment and income.
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Last Thoughts
…to whom much is given, much is required.
- John F Kennedy
The test of our progress is not whether we add more to the abundance of those who have much; it is whether we provide enough for those who have too little.
- Franklin D Roosevelt
- Health care’s focus on identifying
and addressing social needs is absolutely necessary and utterly insufficient.
- We should resist the temptation to
medicalize poverty and social resource needs.
- Do we have the commitment to
health that would logically result in shifting money away from health care over time?*
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