The McMillan Stabilization Center: Update On A Successful Public/Private Partnership

Transcription

1 The McMillan Stabilization Center: Update On A Successful Public/Private Partnership San Francisco Fire Commission July 22nd, 2004 Scott J. Campbell MD, MPH Chairman, SF Ambulance Diversion Task Force

2 EXECUTIVE SUMMARY In 2002, the San Francisco Ambulance Diversion Task Force recommended the creation of a comprehensive chronic public inebriate solution The McMillan Stabilization Center is the centerpiece of a successful ongoing public/private partnership that includes transport mechanisms, detox programs and social services The program is starting to have broad impact, but there are challenges to overcome in order to reach full potential. Proposed action plans have been developed and will need attention to ensure implementation 1

3 SAN FRANCISCO S HOMELESS POPULATION HAS HIGH RATES OF SUBSTANCE ABUSE Margot Kushel MD, SF General Hospital/UCSF Substance Use in the Past Year Among SF Homeless 75% 60% 69% 50% 25% 25% 16% 28% 0% Heavy alcohol use* Any illegal drug use Both heavy alcohol and drugs Either heavy alcohol or drug use Received substance abuse treatment *>5 drinks/day for past month) 2

4 HOMELESSNESS AND SUBSTANCE ABUSE ARE ASSOCIATED WITH HIGH RATES OF MORTALITY IN SF M. Kushel, MD SURVEY OF DEATHS IN HOMELESS SAN FRANCISCANS Average age of death: 41 years 78% of deaths had drugs or alcohol present in system at the time of death 33% were legally intoxicated at time of death 3

5 AND HIGH UTILIZATION OF EMERGENCY SERVICES... M. Kushel, MD Rate of alcohol, substance use among SF homeless, 2001 Percent Frequent ED visits ( 4 per year) Moderate ED visits (1-3 per year) Rate of alcohol, substance use among the homeless population is very high No ED visits All homeless subjects Frequent ED users have higher rates of alcohol, substance use Source: Kushel; American Journal of Public Health,

6 HOMELESSNESS, SUBSTANCE ABUSE AND EMERGENCY SERVICE UTILIZATION ARE CLOSELY LINKED IN URBAN AMERICA New York City 2001: 252 homeless ED visits 81% with alcoholism 71% with depression 27% with schizophrenia Average homeless ER visits per yr = 6 vs. 1.6 controls Los Angeles, 2001: 24% of 2,658 consecutive EMS ambulance patients were CAGE positive for alcoholism Characteristics: Male, Unemployed, Homeless, Poly-sub abuse Seattle 1999: 123 homeless chronic public inebriates utilized $12.3million in ED services 5

7 SMALL NUMBERS OF HOMELESS ARE DISPROPORTIONATE UTILIZERS OF EMERGENCY SERVICES Percent M. Kushel, MD 100% = 2,532 4 visits visits 1 visit 0 visits , Uninsured patients with medical problems are likely using ED frequently for primary care purposes Frequency of ED visits in sampled homeless population Number of ED encounters Source: Kushel; American Journal of Public Health,

8 SOME SF EMERGENCY DEPARTMENTS ARE MORE IMPACTED THAN OTHERS Hospital Council Survey of 8 hospitals over 2 days, 2000 Number of inebriates SFGH 74 St. Francis 19 St. Luke's 15 CPMC-Davies 13 CPMC-Pacific 12 St. Mary's 7 Kaiser 1 UCSF 1 rce: SF Hospital Council, 2000 Source: SF Hospital Council, inebriates in SF EDs over 2 days ~50% of inebriates are seen at SFGH Emergency Department 30% of EMS transports were alcohol related 7

9 Increased ED demand contributes to ambulance diversion VA St. Mary's UCSF Chinese CPMC Kaiser St. Francis Davies Ambulance diversion occurs when an emergency department becomes so congested with patients that it temporarily closes itself to incoming ambulances Closed EMERGENCY SFGH St. Luke's * 8

10 DIVERSION RATES IN SF GREW RAPIDLY from Average monthly diversion, SF hospitals Percent ~1000% increase Hospital diversion hours in SF rose ten-fold from * Compounded annual growth rate Source: The SF EMS System: Impact of Critical Care Diversion, 200; McKinsey anal 9

11 THE INEBRIATE BURDEN CORRELATES WITH AMBULANCE DIVERSION Average monthly diversion Percent St. Francis SFGH R 2 = CPMC-Pacific 10 5 UCSF St. Mary s St. Luke s CPMC-Davies 0 Kaiser Hours occupied by inebriated patients per day/ total ED bed-hours per day Source: SFFD/EMS; Hospital Council; McKinsey analysis 10

12 In May 2001, then Supervisor Gavin Newsom proactively legislated the AMBULANCE DIVERSION task force Scott J. Campbell MD, MPH Chairman Kaiser Permanente Tom Peitz, MD SF Emergency Physicians Association Alan Gelb, MD San Francisco General Hospital Abbie Yant, RN St. Francis Memorial Hospital Mark Pletcher, MD UCSF Ron Smith Hospital Council George P. Susens, MD SF Medical Society Barbara Garcia SF Department of Public Health Rich Shortall SF Fire Department Kym Valadez Swords to Plowshares Rann Parker Mobile Assistance Patrol Alissa Riker Coalition on Homelessness Judith Chavez, RN San Francisco General Hospital Brian Wetzel, RN San Francisco General Hospital Jane Smith SF Fire Department Capt. Mike Puccinelli SF Police Department 11

13 KEY FINDINGS AND RECOMMENDATIONS OF TASK FORCE IN 2002 Key findings from the Diversion Crisis Taskforce work... The cycle of substance abuse and homelessness in San Francisco is a critical public health issue that is difficult to address Chronic public inebriates contribute to an imbalance of supply and demand for emergency services leading to high rates of ambulance diversion Though adequate resources may exist, ineffective coordination of social services results in suboptimal care for these patients Effective models to improve care delivery exist in other major metropolitan areas... led to a set of actionable recommendations for the City Create a comprehensive inebriate solution including Transport support of EMS and MAP McMillan Stabilization Center Links to detox centers Integrated access to social services Enforce current alcohol ordinances Legislate sales in impacted areas Develop a coalition of DPH, private hospitals, EMS/Fire, MAP, McMillan, physician community and advocacy groups to own responsibility for implementation Employ a public/private partnership for funding to share the financial burden and generate incentives for accountability 12

14 ON BALANCE, THE INEBRIATE SOLUTION HAS BEEN SUCCESSFUL Key successes Total transports to McMillan increased by 50% Outstanding safety record Improved health outcomes for patients Building upon successes to address key challenges is critical to reaching the goal of effective inebriate care Opportunities for growth Transport rate from SFGH Transport rate via Fire/EMS Utilization levels at McMillan 13

15 PATIENT SAFETY AND POSITIVE OUTCOMES HAVE BEEN ACHIEVED Patient safety Average of 1 re-transport from McMillan Center back to an ER every 2 months Conservative paramedic triage criteria have avoided accidental transport of emergent medical conditions to McMillan No fatalities Patient safety record is similar to that observed in case studies of services delivered in other cities Positive health outcomes ( Aug 03-June 04) 4,544 visits representing 1,916 unduplicated clients 82% of patients had documented improvement or stabilization in health status Over 300 patients admitted directly from McMillan to social/medical detox Case management services offered to over 750 individuals Frequent ambulance and ER users captured at a rate 4x other patients Multiple examples of long-term sobriety and reduced ER visits 14

16 MCMILLAN S STORY IS PUNCTUATED WITH MANY EARLY SUCCESSES... Case #1 In just 12 months, Mr. X, a 41-year-old Caucasian male, well known to ambulance and ED staff, had been picked up by ambulances 150 times. The ED became his short-term detox. Mr. X has been a steady client at McMillan Stabilization, but it took the case managers some time to engage Mr. X. He finally agreed to accept a hotel room and was linked into General Assistance. Ambulance pick-ups for this client have been reduced from a monthly average of 12.5 to 2. 15

17 And Case #2 Mr. Y, a 40-year-old male who, last year made 35 ambulance calls. Chronically homeless on the streets for years, he had admitted alcohol dependence and multiple encounters with the criminal justice system for minor offenses. Found intoxicated on the streets, Mr. Y was convinced to come to McMillan where he was stabilized. Mr. Y agreed to go into medical detox at Baker Place s Fremont Street where he stayed for several weeks. After graduating from Fremont, Mr. Y attended Ozanam day treatment program and began going to two AA meetings a day. He has been sober ever since and continues to work his twelve-step program. Ambulance and EMS usage has been reduced to zero. 16

18 And Case #3 Mr. Z, a 54-year-old African American male, was well known to the MAP van and paramedic staff. Upon entry to McMillan, Mr. Z s vital signs and mental status were taken according to protocol and were stable. The Nurse Practitioner noticed Mr. Z was quite pale, his gait unstable and he was sweating. A full history and physical were done and the patient was found to have evidence of gastrointestinal bleeding. The patient was taken by 911 ambulance to St. Francis Hospital. His bleeding was stopped and a follow-up appointment was made with a specialist at SFGH. The physician at St. Francis stated that if the patient had stayed out in the streets for one more day he would have died. This doctor praised McMillan staff for saving his life. Since being case managed by McMillan Stabilization staff, Mr. Z has not had another hospitalization or ambulance ride. 17

19 RETURN ON INVESTMENT CAN BE SUBSTANTIAL FOR HOSPITALS THAT UTILIZE THESE SERVICES ROUGH ESTIMATE Number of calls for MAP dispatch/transfer for CPIs ER Jan 2004 SFGH 7 CFMC 4 Kaiser 2 St. Luke s Davies 5 23 Potential EBITDA impact at St. Francis with diversion reduced from 19% to 8% St. Mary s 9 UCSF 6 St. Francis 35 18

20 SFGH HAS OPPORTUNITY TO LIBERATE ER CAPACITY BY TRANSFERRING MORE INEBRIATES TO McMILLAN CENTER SFGH ER to McMillan MAP transports are increasing Monthly transports, Jan April- June Ave Potential SFGH estimate* SFGH leadership action plan ED director ownership and accountability for reporting to: -Hospital bed utilization committee -CEO -Director of Public Health Site visits/knowledge transfer -In-service at McMillan -McMillan Medical Director/SFGH -SFGH ER RNs/St. Francis ER RNs Improve triage of patients to McMillan -Ongoing chart review -Educate ED physicians/residents SFGH action plan developed * From SFGH chart review conducted 4/

21 EMS IS INCREASING TRANSPORTS AS CONFIDENCE IN SAFETY OF MCMILLAN DEVELOPS Average monthly transports directly by EMS to McMillan have doubled Number per month Oct Apr-Jun 04 Mar 2004 Chief Hayes- White action plan Potential Fire/EMS action plan Increase SFFD support Chief of EMS ownership Fire Chief commitment Medical director triage criteria review Improve medic education Targeted at key firehouses McMillan open house ED-EMS feedback telephone hotline Integration of MAP into Call Center 20

22 IMPACT OF DIVERSION TASK FORCE INITIATIVES HAS BEEN SUBSTANTIAL Annual transports Diversion 44,000 50,000 13% 46,000 3% Ave E 10% Impact of Diversion Task Force has been substantial Diversion task force Reduce inebriate burden Implemented Clawson dispatch system Civilianization of call center Highlight system bottlenecks 21

23 KEY ACCOMPLISHMENTS AND AREAS FOR ADDITIONAL FOCUS... What has been accomplished... Creation of an effective solution that targets a top 3 issue, substance abuse, in the cycle of homelessness in SF Effective public/private/academic partnership in a public health solution Broad impact on improving access to medical care by applying leanoperating principles to a throughput problem Demonstrated financial return on investment for hospitals utilizing the services effectively Areas of needed attention Follow-up on suggested action plans and accountability for capturing growth opportunities Maintain private stakeholder enthusiasm for funding public/private partnerships Syndicate success of McMillan model with key stakeholders Next wave ideas/initiatives Enforce current alcohol sales ordinances Consider new alcohol sales legislation in highly impacted neighborhoods 22

24 Feedback... This program has saved our emergency department s valuable resources. Not only do we have more time to serve other ER patients, public inebriates are now getting the services they need and deserve. - ED Medical Social Worker Thank you for providing a safe and caring environment. This is a very difficult population to deal with and you are doing a great job. Finally, there is a place that can help these folks break the cycle of their substance abuse and get the help they need. - SFFD Paramedic 23

25 Thank Yous Honorable Gavin Newsom, Mayor of San Francisco McKinsey and Company, San Francisco Office San Francisco Emergency Physician s Association Hospital Council of Northern California San Francisco Ambulance Diversion Task Force McMillan Stabilization Center Oversight Committee San Francisco Department of Public Health Mobile Assistance Patrol (MAP) San Francisco Fire Department and EMS San Francisco Board of Supervisors Margot Kushel, MD, MPH, SF General Hospital/UCSF 24