1

Jan EldredKaren W. LinkinsLisa Mangiante

December 10, 2008

2

Overview of the Initiative

Five year project funded by The California Endowment and the California HealthCare Foundation, based at Corporation for Supportive Housing California Program

The issue – emergency rooms are inundated with large numbers of patients, many of whom have complex, unmet needs not effectively dealt with in acute care settings

Create a more responsive system of care that proactively– Addresses patients’ need and produces better health outcomes

– Frees up emergency department resources for acute medical crises

3

Who Are Frequent Users?

65% chronic illness (diabetes, cardiovascular disease, chronic pain, cirrhosis & other liver disease, asthma & other respiratory disease, seizures, Hepatitis C, and HIV)

53% substance use issues (alcohol, methamphetamines, crack/cocaine, heroin, prescription drugs)

45% homeless, living on the streets

32% mental illness (Axis I and II)

36% have 3+ of these presenting conditions

4

The Challenge

Disproportionate use by small number of patients

Most use is avoidable– 8.9 ED visits each annually, with average annual charges of

$13,000 per patient– 1.3 hospital admissions annually– 5.8 inpatient days each, with average annual charges of

$45,000 per patient

Episodic, hospital-based care doesn’t effectively meet the multiple, complex needs

5

The Models

6 counties, 6 programs (partnerships of hospitals, health/human service, housing, behavioral health, criminal justice)

5 intensive case management, 1 brief peer intervention

3 hospital-based, 3 community-based Various team compositions ranging from peer

counselors and paraprofessionals to multidisciplinary teams – one with social workers and nurses and the ability to bill for direct services

6

Frequent User Case Management

Key elements Connect patients to both medical and non-medical

services (e.g., primary care, mental health, drug and

alcohol treatment, housing, transportation) Intensive individual support, especially initially Coordination of care Effective linkages between case managers and ED

7

Policy Impact

Increased awareness of frequent users and commitment to address high cost, ineffective utilization patterns

Other initiatives in place that affect some frequent users – Coverage Initiative—expands healthcare to some uninsured (10 counties)– Mental Health Services Act — provides funding to county mental health departments for services

to people w/ serious and persistent mental illness– Coordinated Care Management Program — pilot to reimburse for services to low income people

with medical illness and serious and persistent mental illness in some counties

SB 1738 (2008) Passed both houses with bi-partisan support but vetoed by Governor (prefers “statewide solution”)

Victories: universal agreement on the approach, belief in the data, and Administration and stakeholder commitment to work together next year

8

Local Accomplishments

Most Initiative programs self-sustaining

Broader adoption of case management & multidisciplinary care

Increased collaboration to improve service delivery:– frequent user programs and supportive housing– FQHCs and hospitals– health and mental health agencies, health agencies and jails

Increased focus on benefits advocacy

Collaborative planning of community initiatives for overlapping populations:

– Medical respite for homeless patients– Coverage Initiative for uninsured Californians– 10 year plans to end homelessness

9

Outcomes: Connections to Housing, Health, and Income Benefits

Clients homeless at enrollment:– 34% connected to permanent housing

Clients connected to health benefits:– 68% Medicaid applications approved

Clients connected to SSI:– 53% SSI applications approved

10

Outcomes: Hospital Utilization & Charges

Per Person 1 Year PRE

2 Years POST

% DIFFERENCE

Average ED Visits 10.3 4 61% decrease

Average ED Charges $11,388 $4,697 59% decrease

Inpatient Admissions 1.5 0.5 64% decrease

Avg. Inpatient Days 6.3 2.4 62% decrease

Avg. Inpatient Charges

$46,826 $14,684 69% decrease

11

More information

For more information about the Initiative or to download the Frequent Users of Health Services Initiative: Final Evaluation Report, visit:

www.frequenthealthusers.org