History: Walden House

Transcription

1 Integrating Primary Care and Residential Treatment Decreases ER Utilization History: Walden House Walter Littrell sells his home in Marin to start Walden House at 101 Buena Vista East in San Francisco Walden House is named after the 1948 novel Living Walden Two: B.F. Skinner s Behaviorist Utopia and Experimental Communities Walden House begins with 25 runaway teens who are substance abusers in the Haight Ashbury District

2 After endless neighborhood meetings and six months of treks to City Hall to lobby the Board of Supervisors, Walden House purchases a former convent at 815 Buena Vista West Supervisor Harvey Milk argues passionately on behalf of Walden House Tragically, he would be murdered a month later; The former chapel at the new facility is named Harvey Hall in his honor 2010 Dr. Vitka Eisen is the first graduate of Walden House, Inc. to become it s Chief Executive Officer 2

3 History: The Haight Ashbury Free Clinic The Social Revolution of the 1960s brought with it: Homelessness Drug dependency Impaired mental health 1967 Haight Ashbury Free Medical Clinic founded at 558 Clayton Street First free clinic in San Francisco Haight Ashbury Free Clinic Firsts First Free Clinic with the integration of multiple health disciplines in the provision of community health care First to fully integrate psychiatry with addiction treatment for co occurring disorders Implemented effective alternatives to methadone (Suboxone, Naltrexone, Buprenorphine) 24 hour non residential services for homeless, mentally ill, substance abusing women in San Francisco Implemented acupuncture and alternative medical interventions for SUD clients Advocated the cleaning of needles with bleach by intravenous drug users that led to a needle exchange program to prevent the spread of AIDS 3

4 Haight Ashbury Free Clinic Mission Increase access to health care for all and improve the health and well being of clients Provide high quality, comprehensive health care that is culturally sensitive, non judgmental and accessible to all in need "Health Care is a Right, Not a Privilege." Haight Ashbury Free Clinic Today Integrated Care model with: Primary care Substance abuse treatment services Mental health services Case management including resource referral Services available to all, but clients are primarily people who cannot access other sources of care: Working poor Homeless Youth Individuals with substance abuse and/or mental health issues 4

5 Walden House and the Haight Ashbury Free Clinic merge! A Family of Programs HealthRIGHT 360 now operates as a family of programs, with many different services located all over California. Walden House Women s Recovery Association Asian American Recovery Services North County Serenity House Lyon Martin Glide Haight Ashbury Free Clinic 5

6 Medical Clinics 558 Clayton original clinic 1735 Mission Integrated Care Center The Vision Post merger The merger of Haight Ashbury Medical Clinics and Walden House envisioned a in house network of bilateral referrals between residential treatment facilities and primary care clinics. Residential Substance Abuse Treatment Haight-Ashbury Medical Clinic Community Health Network 6

7 Residential Procedure prior to Integration Efforts There was no collaboration or coordination between Residential Treatment and Primary Care May have led to negative outcomes for the client while seeking services. 7

8 Most Health Issues Went to an Emergency Room Previously, there were no established protocols. Staff at the residential facilities would call 911 or send their client to seek medical services elsewhere. Nothing else they could do Staff are not medically trained Largely uninsured population Liability issue in not calling ambulance Baseline Data Collection 8

9 One-Agency Data Sharing Policy Baseline Data Collection Needed to know the scope of the problem so we began tracking ER visits made by residential treatment clients Week of: Client ID Date of ER/Hospital Visit Reason for ER/Hospital Visit How was s/he Transported to the ER/Hospital Hospital/ER Name Time of Day 9

10 Sample ER Visit Reasons Date of ER Visit Reason Method of Transport Time Hospital Facility 4 Nov 13 Blurry vision, nausea Bus 6:21 AM SFGH 815 St. 4 Nov 13 Fell and bumped her head. Ambulance 911 2:55 PM Mary 's Nov 13 Hand swollen and warm following insect bite Bus 2:30 PM SFGH FOTEP TI 5 Nov 13 Pain in back and abdomen Bus 11:20 PM SFGH FOTEP TI Many of these incidents could and should have been treated appropriately in a primary care setting. ER Visits by Residential Clients in the Eight Weeks Prior to Integration Efforts (N=65) Categorized using New York University Emergency Department methodology - Billings, Parikh & Mijanovich, 2000 Level Of Acuity Number of Occurrences Definition Examples of Reasons for ED Visits Client's initial complaint, vital signs, medical history, and Non emergent 4 (6.15%) age indicated that immediate medical care not required Headache, bad back, toothache within 12 hours. Emergent/Primary care treatable 21 (32.3%) Emergent/ED care required but preventable or avoidable Emergent/ED care needed, not preventable or avoidable 19 (29.23%) 18 (27.7%) N/A 3 (4.62%) Treatment was required within 12 hours, but care could have been provided in a primary care setting. The complaint did not require continuous observation, and no procedures were preformed or resources used that are not available in a primary care setting. Scabies, flu, stomach pain, pain in side Emergency care was required based on the complaint or procedures or resources used, but the emergent nature Difficulty breathing, asthma attack, blurry of the condition was potentially preventable or vision, high blood pressure avoidable if timely and effective primary care had been provided. Emergency care was required and primary care treatment could not have prevented the condition. Reason not given or reason given did not include enough information to categorize. Mental health concerns, self harm, ETOH withdrawal, chest pain, badly cut finger, seizure symptoms 10

11 Post-merger Integration Efforts Staff Education Three tiered classification Intervention Patient Education Tb test as a gateway Linkage to Primary Care Referral System 11

12 Staff Education Clinic staff attended a manager level meeting of residential treatment staff to educate about the clinic and the potential benefits the merger offers clients Clinic began providing on call consultation to residential treatment staff to help them decide what constitutes a need for emergency treatment Clinic staff attended another manager level meeting of residential treatment staff to reinforce the learning of the information about the clinic and the potential benefits the merger offered clients and to educate staff about the on call consultation and the medical home model 3-Tiered Classification for health concerns Director of Healthcare Operations drafted and distributed a 3 tiered classification system for residential staff to use as a reference Non urgent; during clinic hours Urgent; during clinic hours Any health concern after clinic hours Encouraged Managers to call Director of Healthcare Operations for urgent issues and same day appointments. 12

13 Patient Education Patient centered medical home model TB Test as a gateway Created an educational and informative video 13

14 Medical Home Model In an effort to capture clients already in residential treatment, the client s Medical Home information was added to the facility s pop sheet Clinic front desk verifies medical homes for all patients coming in to the clinic to get a Tb test for residential program admission. For clients with no identified medical home or insurance, screening is conducted and enrollment process begun for health insurance. This is either done same day or an appointment would be made for the client to return with all necessary documents. A reminder goes out to the case managers in the facility to remind the patient of their scheduled appointment. If a client didn t have a Medical Home, staff provided psycho education to inform them of the potential benefits HealthRIGHT 360 is presented as an option TB Test as a Gateway All clients entering our residential programs are required to obtain a TB clearance. Almost all of them obtain this clearance at the HAFC because: They are unlikely to have documented test results sufficient to fulfill the requirement prior to intake The clinic and TB testing capabilities are in the same building as the intake process (co location). This is an excellent opportunity because many individuals have not had access to medical care. It is a great way to introduce them to our medical staff and get them to utilize these services. 14

15 Linkage to Primary Care Director of Healthcare Operations and the Director of Mental Health Operations meet to work out a referral system between mental health and primary care. This served as a supportive option to the process outlined above. These referrals depending on acuity could be for same day or next available appointment. Linkage to Primary Care Patients who choose HR360 as a medical home get set up with a B # This gives us access to their medical records through their Lifetime Clinical Record (LCR) San Francisco General Hospital's electronic medical record Used to look up clinical information and initiate specialty referrals, view specialty notes, lab results and receive any relevant clinical notifications. 15

16 Communication Providers keep agency mobile phones for communication between residential and the clinics Accessible throughout the day 16

17 Special Cases/Urgent Needs Director of Healthcare Operations and the Director of Mental Health Operations meet to work out a referral system between mental health and primary care. This served as a supportive option to the process outlined above. These referrals depending on acuity could be for same day or next available appointment. ER Utilization Data 17

18 Clinic Days of Operation Clinic normally operates Monday through Friday Integration with the System of Care Once individuals have accessed and been enrolled with HR360 clinics as their medical home, they are connected with San Francisco Department of Public Health s Community Health Network Gives them access to specialty, emergency and pharmaceutical services. 18

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20 Next Steps and Future Research Expand intervention to other HealthRIGHT 360 facilities For clients who become connected to a medical home, do they keep follow-up appointments? Does access to healthcare during residential treatment improve treatment outcomes or length of stay? Are referrals to residential or outpatient treatment beginning to come from primary care? 20

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