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Maria X Martinez
1. Urgent/Emergent Care and challenge 2. HUMS hypothesis 3. High users, multiple systems, and multiple
domains of disorders 4. Was FY 11-12 different? 5. IDS goals:
1. Targeted Street Outreach (EST)
2. Coordinated Case Management
3. Ambulatory Acuity Index
Medical System EMS transports ED medical Inpatient – 24hr Medical Respite (hospital
offset) Urgent care clinics at
TWHC, hospital
*Programs in red are the only ones studied
in other communities.
Psychiatric Sytem PES, Dore St (PES offset) Psych Inpatient – 24hr Adult Diversion Units
(hospital offset) – 24hr Crisis clinics at Westside,
Mobile Crisis
Substance Abuse System Sobering Center Res Medical Detox – 24hr Res Social Detox – 24hr
“High Users of Multiple Systems”
2007 study showed common features for high ambulance users: costly, multi-disordered, receiving care in multiple service agencies, unknown to individual systems, not sticking to any stabilizing services, and no care coordination.
HUMS Hypothesis: Coordinated care, supported by integrated data, can be an effective intervention to reduce costs and improve health outcomes.
$200 million annual urgent/emergent care estimated actual costs
50,000 – 55,000 unique individuals served annually
Top 1% of individuals account for 25% of costs.
Top 5% account for 55% of costs.
Summary of FY 10-11 # Patients Total Costs
% Total Costs
Ave Cost/Pt
Ave # Svcs
Top 1% 511 $49,793,566 25% $97,443 89
Next 2 - 5% 2,078 $58,527,401 30% $28,165 30
Remaining 95% 49,207 $88,187,508 45% $1,792 2.5
Totals 51,796 $196,508,475 100%
Number patients in each group, FY 10-11
Any 1 sys Any 2 sys All 3 sys totals Ave
Top 1% HU 199 175 137 511
Next 2-5% HU 1,009 800 269 2,078
Remaining 95% 46,344 2,654 209 49,207
Totals 47,552 3,629 615 51,796
HUMS 312
Average Urgent Care Cost per Individual FY 10-11
Any 1 sys Any 2 sys All 3 sys totals Ave
Top 1% HU $94,375 $98,148 $101,000 $97,443
Next 2 - 5% HU $27,311 $28,281 $31,028 $28,165
Remaining 95% $1,584 $4,913 $8,308 $1,792
Totals n/a n/a n/a
HUMS
FY 10-11 1 sys 2 sys 3 sys TotAve FY 11-12 1 sys 2 sys 3 sys TotAve
Top 1% 86 90 93 89 Top 1% 85 91 92 89
Next 2 - 5% 29 30 33 30 Next 2 - 5% 28 30 33 30
HUMS HUMS
No, average number services per urgent care patient is same.
FY 10-11 1 sys 2 sys 3 sys TotAve FY 11-12 1 sys 2 sys 3 sys TotAve
Top 1% HU
$94,375 $98,148 $101,000 $97,443 Top 1%
HU $104,365 $82,862 $57,488 $85,449
Next 2-5% HU
$27,311 $28,281 $31,028 $28,165 Next
2-5% HU $32,073 $21,367 $17,703 $26,498
HUMS HUMS
Yes, average cost per patient decreased for multi-system users, but increased for single system users.
Ambulatory Acuity Index Targeted Outreach Coordinated Case Management
Multiple Systems
1 system 2 systems 3 systems
SA Psy Med SA-Med SA-Psy Psy-Med Tri Totals
Top 1% HU - 56 143 44 6 125 137 511
Multi-disorders measured by Elixhauser Co-morbidity Index
0 Domains*
Diagnosis in 1 Domain
Co-Morbidity Diagnosis
Tri-Morbid
No Elix SA Psy Med SA-
Med SA-Psy Psy-Med Totals
Top 1% HU 12 5 8 52 81 63 58 232 511
* 0 Domains usually means the patient received urgent care services for acute, resolving condition; not chronic, progressive condition
30 diagnostic measurements add together to form final score.
Even a single positive response predicts early mortality if untreated.
All conditions are progressive without treatment.
Most conditions are chronic. They can be ameliorated and stabilized with treatment.
Some conditions are acute. They can be cured with treatment.
Circulatory System Cardiac Arrhythmias Valvular Disease Congestive Heart Failure Hypertension, Uncomplic. Hypertension, Complic. Peripheral Vascular Dis. Pulmonary Circulation Dis.
Digestive System Liver Disease Peptic Ulcer Disease, Excl
Bleeding
Endocrine System Diabetes, Uncomplicated Diabetes, Complicated Obesity Weight Loss Hypothyroidism
GenitoUrinary System Renal Failure
MusculoSkeletal System Rheumatic Arthritis /
Collagen Vascular Disease
Hematology System Deficiency Anemia Blood Loss Anemia Coagulopathy Fluid and Electrolyte
Disorders
Neurological System Paralysis Other Neurological
Disorders
Respiratory System Chronic Pulmonary Disease
Cancer Solid Tumor w/o Metastasis Metastatic Cancer Lymphoma
Immune System AIDS/HIV
Psychiatric Disorders Psychoses Depression
Substance Use Disorders Alcohol Abuse Drug Abuse
SFHOT Engagement Specialist Team
Targeted street outreach with the goal of more effectively engaging and placing HUMS into care (warm handoffs and follow-up)
24-hr schedule
Covers grid based upon CCMS knowledge of ambulance pickup histories
Responds to 311, police, EMS for street intervention
Transportation to & from urgent/emergent facilities
Current: HUMS Clinical Case Conference – monthly
EST Planned: Central call-in line for EDs to consult with EST and
RNs at Sobering Center (use of CCMS)
Addition of electronic case coordination tools including provider communication and oversight of “community care plan”
EST assist in finding patients who were engaged with case managers but have been “lost to follow-up”
HUMS + conditions are useful way to monitor high cost / high risk patients
HUMS method helps plan interventions to improve health outcomes and reduce costs
EST and Care Coordination changing interactions with HUMS patients
Further interventions and grant applications are planned
Spotlight may be reducing costs already
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