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San Francisco Department of Public HealthSFHN TRANSITIONS DIVISION

Presented by: Kelly Hiramoto, LCSW, Director of SFHN TransitionsJune 20, 2017

Director of Health

Finance Policy & Planning

Zuckerberg San Francisco General

Laguna Honda Hospital

Transitions

Managed Care & Patient Finance Ambulatory Care

Primary Care

Behavioral Health

Jail Health

Maternal, Child & Adolescent Health

Human Resources

Information Technology

Coordination of Division Initiatives

Environmental Health Community Health Equity & Promotion

Disease Prevention & Control

Public Health Emergency Preparedness & Response

Emergency Medical Services

Office of Equity & Quality

Office of Ops, Finance & Grants

Mgmt.Center for Learning &

Innovation

Applied Research, Community Health

Epidemiology & Surveillance

Center for Public Health Research

Bridge HIV

Security Communications Compliance & Privacy Affairs

Health Commission

Department of Public Health Organizational Chart

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Transitions DivisionWho We Are

Transitions Org Chart-Staff ver 17-06

DIRECTORKelly Hiramoto, LCSW

SF BEHAVIORAL HEALTH CENTER

Linda Sims, RNAdministrator

MHRCRCFEARF

Hummingbird Psychiatric Respite

[Staff Roster Available Upon Request]

PLACEMENT

Elayne Hada, RN, DirectorPerrie Ancheta, MFTiJennifer Esteen, RN

Daniel Ip, LCSWJessie James, HW3Susanna Kiely, RNSusan Noble, RN

Annette Quiett, LCSWAnnie Shui, MFT

Sharon Singletary, MFTJoseph Steward, RNCindy Sung, ACSW

Adam Udlis, RNDierdre Veals, Clerk

OPERATIONSDavid Sickles, RN

Valerie Lai, Sr. AnalystGary Scherer, MFT

Harriet Lem, Health Educator

CARE COORDINATION

Luis Calderon, DirectorJamilla Anderson, HW2

Maria Cumiskey, RNKhoi Dang, LCSWDanna Falla, PHNEmily Ho, MSW

Stacey Johnson, RNRoberta McGowan, RNPatricia Rodriguez, SW

Alice Yue, PHNvacant, SW

STREET MEDICINE

Barry Zevin, MD ,Medical DirectorJason Blantz, NPGina Limon, RN

Leah Warner, NPLinette Martinez, MD (PartTime)

Shelter Health*Kate Shuton, PHN, Supervisor

Kristin Matteson, RNVirginia Bryant, RNAngella David, HW2

Clara Lusardi HW2 (Part Time)*partnered with TWUH

DEPUTY DIRECTOR(vacant)

Administrative SupportFrances Yee, Eligibility

Marilou Panganiban, Billing

Business Office*Shared with

Behavioral Health

Psychiatric/Medical Consultation

Dr. Deborah BorneDr. David Kan (Part time)

(vacant Psychiatrist part time)

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Transitions DivisionService

What we do…

The goal of the Transitions division is to ensure clients are stabilized in the most appropriate, least restrictive setting in the most cost effective manner.The Team provides Utilization Management for length of stay, Care Coordination and Case Management to support flow.

Whom we serve… Severely Mentally Ill SFHN members with

Multiple Complex characteristics Mental health Substance use issues Medically compromised Cognitive impairments

High inappropriate users of SFHN care systems We consult on those in need

of subsidized placement to leave the hospital or support for the wraparound care plan

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• Treatment• Shelter• Hotel aka SRO (single room occupancy), Stabilization Room• Support Service Hotels• Co-operative Housing• Direct Access to Housing and Shelter + Care• Residential Care aka “Board & Care”

- RCF/ARF: 18 y.o. – 59 y.o.- RCFE: 60 y.o. and older

• Mental Health Rehabilitation Center/Institute for Mental Disease/Locked SubAcute Treatment

• Neuro-Behavioral Skilled Nursing Facility (SNF)- Chronic Inebriate Program

• Medical SNF• State Hospital

Transitions DivisionLevels of Care

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• Acute Psychiatric and Medical Units at SFGH and Community Hospitals

• Acute Diversion Units, Residential Treatment (Mental Health, Substance Use and Dual Diagnoses), Transitional Residential

• Residential Care Facilities (Board & Care)

• Locked settings: IMD/MHRC/Neurobehavioral SNF

• Laguna Honda Hospital and Rehabilitation Center

• Community Settings

• Jail

• Emergency Departments: Psychiatric & Medical

• State Hospitals

Transitions DivisionWhere We Do It

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Transitions DivisionCommunity Placement Average Bed Census

FY15-16Location Average Bed Census

State Hospital 46

MHRC/IMD 93

Neurobehavioral SNF 148

Adult Residential Care 381

Older Adult Residential Care 341

Stabilization Hotel Rooms 25*

Mental Health Full Service PartnershipStabilization Hotel Rooms 14

* Current FY average of 20 hotel beds predominantly at 16th Street Hotel

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Level of Care Clients Served CostIMD (out of county only) 78 $4,766,389

Neurobehavioral SNF 182 $6,628,895

Adult/Older Adult Residential Care 898 $9,698,321

MHRC/IMD Average Length of Stay

Facility <1 Yr 1-3 Yrs 3-5 Yrs 5-10 Yrs >10 YrsCanyon Manor 4 1 6 1 3Crestwood Angwin 0 1 0 2 0Crestwood Vallejo 14 19 3 1 2

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Residential Care Facilities

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Transitions DivisionCare Coordination: HUMS

High Users of Multiple Systems* (HUMS)Outcomes for FY 14-15

3,711 people tracked• 136 people had at least 100 urgent or emergent services costing

SFHN $18.1M• 11 are tracked as High Users of Single System (medically frail)

costing SFHN $1.8M

65 placements• 33 placed in Community Placement beds• 25 housed in DAH units• 7 returned home out of SF often accompanied by Transitions RN

•Only includes systems that are able to share data with SFHN:EMS, ZSFGH, PES, Shelter, Jail, Medical Respite, SFHOT

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Transitions DivisionPhillip’s Journey

• In FY14-15, Phillip had 136 urgent and emergent encounters at a total cost of $158,335.

• SFHN Transitions Care Coordination facilitated his discharge to a stabilization room with wrap around services.

• Phillip went from 40 ED visits in FY14-15 to 1 in FY15-16.

• He went from top 1% HUMS in FY14-15 to not showing in the HUMS list in subsequent years.

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Transitions DivisionDavid’s Journey

• In FY14-15 David had 194 urgent and emergent encounters, at a total trackable cost of $194,020

• A chronic inebriate, David was contemplative towards treatment when we started engaging with him at ZSFGH but it was impossible to find a treatment facility in San Francisco because he is a registered sex offender.

• David remained contemplative after being placed in a temporary hotel room.

• After arranging detox at the Sobering Center, we placed him in a Sober Living Environment in Oroville. He remains in the program with no new urgent or emergent costs to SF.

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Transitions DivisionChallenges

Dementia Resources: few to no custodial care dementia facilities

Shrinking availability to step down: Other counties increasing purchase of Locked Psychiatric beds for their MIST clients, Board & Care closures, increasing Board & Care costs, GGRC and other entities are buying Board & Care beds, decrease in available Stabilization Rooms

Shelter Bed access: no dedicated beds for hospitals or high users so dependent on collaboration with SFHOT

Substance Use Disorder management: treatment resistance

Forensic Clients: Dramatic increase in 1370 “MIST” Misdemeanor Incompetent to Stand Trial and State Hospital Returns

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Transitions DivisionLooking Forward

FY 2017-18 budget includes 116+ new behavioral health beds:• 15 beds at Hummingbird Place at the Behavioral Health Center on

the ZSFG campus• 34 new medical respite beds (funded in 2015, opened in 2017)• 30 + Mental Health Rehabilitation expansion beds in San

Francisco• 32 residential substance use disorder treatment beds• 5 detox beds• Whole Person Care Partnerships• Collaborative Courts• Drug Medi-Cal• Assisted Living Waiver• Dementia care resources in collaboration with DAAS

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Thank you!

QUESTIONS

ANSWERS