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Empowering Patients to Improve Health and Reduce Hospitalizations, ED Visits

The General Medicine Clinic (GMC) at San Francisco General Hospital (SFGH) was struggling with a high rate of repeat admissions. In fact, a 2011 analysis showed that 2.7 percent of GMC patients accounted for 35 percent of admissions. Although many of the diagnoses for these admissions could be treated in the ambulatory setting, the traditional primary care provided by the clinic was failing to stabilize these patients. SFGH formed the GMC Care Management Program to decrease hospitalizations and emergency department (ED) visits while improving health outcomes through focused care coordination and health coaching. As a result, patients are reducing hospital and emergency department (ED) visits and learning how to care for themselves.

SFGH looked to programs such as Wishard-Eskenazi Health’s GRACE (Geriatric Resources for Assessment and Care of Elders) to understand how to improve health, quality of life, and hospital use in chronically ill people. “Given the success of care management in geriatric, homeless, and psychiatric populations, our SFGH leadership believed that these patients could benefit from care management as well,” explains Elizabeth Davis, MD, GMC’s assistant medical director.

With this idea in mind, staff met with multiple stakeholders and partners, including the San Francisco Health Plan and the San Francisco Department of Public Health (SFDPH) case management, supportive housing, and primary care departments to share best practices and avoid redundant services. They also developed a training program for staff focused on motivational interviewing and self-management. SFGH leadership played an integral role in the clinic’s start-up, including providing funding through the Centers for Medicare & Medicaid Services’ Incentive Program funds, part of California’s 1115 Medicaid waiver. “The executive leadership of SFGH has fostered this project through direct mentorship and has connected our team to other similar programs in [the area],” Davis says. “They instilled in our team a commitment to using data to drive improvement and measure progress toward our goals.”

The Program in Practice

GMC staff identify prospective patients using utilization data and referrals from multiple sources, including providers, the San Francisco Health Plan, and hospital-based programs. They also partnered with SFGH’s ED case management program to develop a strategy for determining which referrals would be more appropriate for the more intensive ED program and vice versa.

Once patients are identified, the program team – a registered nurse (RN), a medical assistant trained as a health coach, a program coordinator, a social worker, and a physician – conducts a comprehensive patient assessment, which often takes place in the patient’s home. “By working with patients in their homes, teams can gain important insights into their patients’ social network, medication knowledge and skills, and ability to do self-management,” Davis explains. The home visits also build trust between the family and the team.

Using the assessment, the team develops a patient-centered care plan that includes patient and primary care provider goals. Patients are assigned a level of care that determines the intensity of their care management program. Critical patients receive intensive case management in the first two weeks with multiple check-ins (either in-person or over the phone) per week. More stable patients follow a lesser program, which may consist of biweekly or even monthly check-ins. The levels of care are dynamic, and patients can move fluidly up or down depending on need. As patients improve, they drop to lower acuity levels, allowing greater program capacity. “Our goal is to empower patients and eventually graduate them from our program,” Davis says.

The health coach proactively coaches patients toward care plan goals, while the RN focuses on complex clinical issues, resolving rising problems before they become critical. The RN and health coach have frequent contact with primary care providers and round weekly with the program physician, social worker, and coordinator. Patients can also reach the team by phone at any time with questions or concerns. The team meets weekly to discuss new patients and particularly complex patients. If patients are admitted to the hospital, the team visits them there, works with inpatient providers, and provides post-discharge care.

Continuous Improvement

The team tracks data continuously and reviews it regularly. A weekly dashboard includes a snapshot of the total number of hospital days pre- and post-enrollment for patients in the program for at least six months. It also shows the past week’s activity (home visits, phone calls, etc.) compared with average activity. The team meets weekly and reviews a roster of all patients sorted by acuity level. Patient utilization data are reviewed on a quarterly basis, with plans for automation and more frequent review. Using these tools and methods, the team can focus care on the highest-acuity patients and identify ways to improve day-to-day efficiency.

Patient and provider satisfaction are also important measures of success. Providers are surveyed regarding their patients’ quality of care, understanding of medications, access to social programs, and a host of other issues. Patients also provide feedback in survey form and via the patient advisory board, which meets every four to six weeks.

To gain external improvement support, the team participates in SFDPH working groups on case management and care transitions. To share lessons learned, team members also work closely with other SFDPH primary care clinics that are launching similar programs.

Seeing Results

With 50 patients enrolled and more than 50 on the waitlist, on average the team completes 5 clinic visits, 31 consults with other providers, 1 discharge, and 62 phone visits per week, in addition to the home visit for each patient during enrollment. Preliminary data show that patients in the program have seen a reduction in hospital days by 49 percent and ED visits by 21 percent, compared with the year prior to enrollment. Even with this early success, the team notes that the benefits of care management programs often come after a year of program participation. We look forward to checking back in as they reach that milestone.

For more information about the GMC Care Management Program at SFGH, please contact:

Elizabeth Davis, MD
Assistant Medical Director
General Medicine Clinic
San Francisco General Hospital


About the Author

Laycox is a former senior writer/editor for America's Essential Hospitals.

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