Team approach cuts costs for the chronically ill

Efforts go beyond traditional hospital care

A team approach and intensive case management of patients has helped San Francisco General Hospital cut the number of hospitalizations and costs for patients who were frequently hospitalized.

The team’s efforts go far beyond traditional hospital care and may include help with housing, transportation, and other barriers to obtaining health care. They help the patients navigate the complex and confusing social and health care system.

Among the first 15 patients who stayed in the case management program for a year, admissions were cut in half and median hospital days per patient dropped from 23 to 10.

The program started as part of the hospital’s efforts to determine why some patients were dropping through the health care safety net.

"When we studied our patient population, we found that a very small percentage of our overall population drives 45% to 50% of the cost. About 80% of the patients have had one hospitalization in a year, but 13% had three or more hospitalizations within a 12-month period of time," says Elyse Miller, LCSW, clinical director for the medical high use case management program at San Francisco General Hospital.

The study determined the patients were overusing the primary care clinics and overusing the inpatient ward and developed a multidisciplinary team to tackle the problem.

The team includes Miller; the clinical directors; Michelle Schneiderman, MD, a medical director; three social workers, Ana Carcamo, MSW, Suzane Hufft, MSW, and Donn Warton, LCSW; a part-time psychiatrist, William Mains, MD; and a full-time nurse, Lin Zenki, RN.

The team meets twice a week for medical rounds, once a week for staff meetings, and once a week for a seminar to either discuss patient care or a didactic on medical or psychiatric issues.

"We are a roving multidisciplinary team. We go to patients’ homes within the community if that’s what it takes," she says.

The team recruits inpatients and asks them if they would like to participate in the program. Patients must set goals for themselves and agree to certain medical goals. "It’s a matter of collaboration and compromise," Miller adds.

Each day, the team receives a computer-generated report of patients who were admitted the previous day and who have had three or more admissions in 12 months. The social workers visit the patients in the hospital, screen them, and try to recruit them. Inpatient social workers, physicians, and public health nurses also refer patients to the program.

Patients eligible for the program cannot be enrolled in another program that duplicates the services and must have a life expectancy of at least six months. The program is voluntary, but the patients have to agree to set goals and to be motivated to try to reach them. The social worker case managers typically carry a caseload of just 15 patients because of their intensive needs and complicated medical conditions.

"These patients have multiple impairments, significant medical issues, and underlying psychiatric and substance-abuse issues. Most of their chronic medical issues. such as congestive heart failure, diabetes, and chronic obstructive pulmonary disease, are compounded by drug and alcohol use," Miller notes.

Two-thirds of the patients are or have been homeless or marginally housed. About 80% have a mental illness, and 90% have alcohol and substance-abuse problems. The patients’ care is too complex for a primary care physician to address during a standard clinical appointment, she adds.

Many of the patients have low literacy or a low educational level. Some have sustained multiple impairments that make it impossible for them to be organized. "These are patients with a low level of functioning but with a high level of need to follow up with their care. They need to complete a significant number of appointments with the specialty care clinics and take medication daily," she says.

The team was set up to facilitate the existing system, rather than creating a separate system to manage the patients’ care. It works with the primary care physician, who delegates part of their responsibility for the program.

The team acts as a system translator and breaks everything the patient must do into steps to make it easier for the patient to follow. For instance, the team simplifies medication management, a significant problem for the population in the program.

When patients enroll, the case managers get a list of all the medications the patient is taking. The nurse organizes all the medications the patient is taking in a box with compartments for different times of day. "Some people are on 10-plus medications that they take four times a day. It would be challenging for someone with a college education without significant substance issues. It’s impossible for our population, and they are set up to fail," Miller explains.

The team works with the primary care physician to simplify the medication schedule to make a significant difference in the patient’s symptoms and be the most efficient for the patient to adhere to. For instance, instead of taking medications four times a day, the patient may be able to take it twice a day. The nurse puts the medications for the morning in one side of the box and the evening medications in the other side.

"Maybe the patient is only 80% adherent, but that can make a huge difference," she says.

The team helps patients get transportation to and from the physician or clinic and helps them get a medication card. "We do a lot of simple things that can make a tremendous difference," Miller says.

Finding stable, permanent housing is a big challenge. "In San Francisco, housing is difficult for the mainstream population; but for someone on SSI or general assistance, it’s almost impossible," she admits. Finding safe housing takes the longest amount of time. The city has supported-living hotels for people who meet certain criteria, for instance those who need mental health services or medical care. "The social workers keep up with which facilities have availability and make sure the patient’s names are on the waiting list and that the paperwork needed for admission is done.

"Housing is hard to find, particularly housing with a support staff. A single-room occupancy hotel is $600 to $700 a month, and the average disability check is $849. That doesn’t allow for much padding. We try to get them into subsidized hotels, where the rent is one-third of their income," Miller explains.

If the patient has enough medical or psychiatric issues to qualify, the team may work to get the patient switched from general assistance, a welfare program, to another program that will provide a higher level of assistance, so he or she can qualify for MediCal.

"All of these little things can make a huge difference in a patient’s enjoyment of life and can make a difference in their hospitalization patterns and the cost of their care," Miller explains.

The team is flexible enough to work with people who live an alternative lifestyle. "Instead of trying to push them into a mainstream process, we try to meet them where they are, get their medical symptoms stabilized, deal with their psychological issues, and get them on the right medication," she says.