Sobering Center Collaboration with EMSCLEMENT YEH MD

MEDICAL DIRECTOR

SAN FRANCISCO FIRE DEPARTMENT

Backgroundu Prior to development of the Sobering Center (in 2003), nearly one-third of all

ambulance transports to the ED were for homeless individuals intoxicated on alcohol. (Lelchuk, I. (2005). S.F. tries to aid homeless alcoholics. San Francisco Chronicle)

u Chronic public inebriates make up more than 20 percent of all ED visits with rates five to 10 times the general population rate. (Kushel, M. et al. 2002. Emergency Department Use Among the Homeless and Marginally Housed: Results From a Community-Based Study)

u EMS “superusers” encounters with EMS system are associated with alcohol use. (Hall, et all, EMS-STARS, 2014)

u In 2016, 25% of all Superuser encounters related to ETOH. (SFFD Data 2016)

u $18 Million unreimbursed costs annually in SF related to alcohol. (Lewin Group Study, 2010)

San Francisco Sobering Center

u Program of the SF Department of Public Health (SF DPH), co-located with Medical Respite.

u Started in 2003 in conjunction with Hospital Council.u Mission: The mission of the San Francisco Sobering Center is

to provide safe, short-term sobering and care coordination for acutely intoxicated adults in San Francisco.

u Goals: 1) Reduce inappropriate use of emergency department resources. 2) Decrease the inappropriate use of ambulance transports for acutely intoxicated individuals. 3) Increase care coordination for chronic inebriates.

u 24/7 Nurse-led programu 12 beds (8 male, 4 female)u Two on-site social workers (Jan 2016) and Part-time NP in

collaboration with UCSF(June 2017)

EMS triage to Sobering Centers uBe medically appropriate by meeting all

the following criteria:

u Indication of alcohol intoxication (odor of alcohol on breath, bottle found on person)

uGCS 13 or greater

uPulse 60-120

uSystolic BP >90

uDiastolic BP <110

uRespiratory Rate 12-24

uOxygen Saturation >89%

uBlood Glucose 60-250

uNo active bleeding

uNo bruising or hematoma above clavicles

uNo active seizures; and

uNo laceration that has not been treated

Sobering Center: Encounters and Clients

u Referral sources include: EMS, EDs, Police, Case Management, Clinics, walk-in

u Total encounters since 2003 = over 56,000 at this point

u Total unduplicated clients = over 15,000 individuals

u Total admissions from EMS/ambulance directly (avoiding the ED altogether) = over 15,000 encounters

u 1% of total High Utilizer Clients make up 29% of total encounters.

u 20 clients receiving Intensive Case Management through on-site social workers

Transport volume• Total (‘17 – ’18): 1355 EMS transports to Sobering (Avg: 59/month)

• Accounts for 15% of intake volume into the Sobering Center

San Francisco Fire Departmentu Provides fire suppression and emergency medical services

u Services an estimated daily population of 1.5 million

u 45 Engine Companies

u Over 30 ALS ambulances at peak hours

u 64,000 + transports in 2017

u EMS6 team

EMS-6 Team

u Multidisciplinary Mobile Integrated Health Team

u SFFD/DPH/HSHu Operations began

January 2016u OSHPD/EMSA Community

Paramedicine Pilot Project 2018

u Mission: To improve community health by linking medical, behavioral and social resources for frequent users of emergency services

Coordination with EMS-6• An EMS-6 Community Paramedic and Sobering Charge RN

do a weekly data review of all transports in and out of the Sobering Center.

• Increased collaboration between Sobering and EMS

• Real-time coordination

• Active care plans for high-utilizer and Sobering ICM clients

• Many high utilizer clients offered walk-in privileges to decrease EMS transports

• CP attends first part of monthly Sobering staff meeting to provide updates

• Increase in connections to chronic care mgmt, medical detox and substance use services, move-ins to supportive housing

• Sobering and EMS-6 teams work collaboratively to

get (and keep) clients in medical detox

• 21 clients (that came in via EMS) discharged

directly to Medical Detox during ‘17-’18

Secondary Transports• Secondary Transport: an EMS intake to Sobering

that is then repatriated to the ED after less than 6 hours.

• All secondary transports are reviewed by the Pilot team

• Report generated by Community Paramedic includes:

• Paramedic Patient Care Records (admitting and discharge); Sobering staff clinical notes; ED chart and/or interviews with ED staff

• CP Report is evaluated by Pilot team:

• EMS-6 Community Paramedics, Sobering Center Charge RN and Program Manager, SFFD Medical Director and PhD level RN contracted as part of EMSA pilot

Secondary Transports• Feb 2017 – Dec 2018: Total of 27 Secondary

Transports (<2% of total intakes)

• Historically, the secondary transport rate is 3-5%

• Only 1 secondary transport was the result of miss in the field

• Client was tachypneic in the field but declining transport to an ED.

• Community Paramedic coordinated with management of private EMS company.

• Also provided direct 1-on-1 coaching to field medic and more appropriate designation based on respirations in the field.

• The Sobering Center also tracks refusals by RN staff. There have been 3 admissions that have been declined admission and repatriated to the ED.

Frequent Users

u No consensus definition

u 2 or more 911 activations in the same calendar day

u 4 or more 911 activations in the preceding 30 days

u 10 or more 911 activations in the preceding 365 days

u If you aren’t sure, contact us!

Frequent Utilization2014* 2015* 2016** 2017** 10/30/17-10/3018***

Unique 911 users 42,250 46,898 50.025 47,281 42,452

Unique frequent utilizer 264 312 452 515 1,083

% that are frequent utilizers 0.62% 0.67% 0.90% 1.09% 2.55%

2014* 2015* 2016** 2017** 10/30/17-10/3018***

911 transports all 50,531 57,597 61,168 64,452 65,229

911 transports attributed to frequent utilizers 7,064 8,217 8,144 11,097 12,881

Frequent utilizers as a % of transports 13.98% 14.27% 13.31% 17.22% 19.75%

Data Compiled from SFFD Sources Only (No Private Ambulances)*Limited data. Frequent utilizer definition >9/preceding 365 days only

**Frequent utilizer definition >9/preceding 365 days only***Frequent utilizer definition all three criteria. Data compiled with matching algorithm

2017: 1,887 referrals

u Housing

u Primary care

u Behavioral health Substance abuse treatment

u Navigation centers

Sobering19%

Detox10%

Shelter13%

Medical: hospital based29%Clinic

1%

Psychiatric4%

Social Services

3%

HOT9%

Food3% Medical:

non-hospital

9%

Whole Person Care: Prehospital Action Plans

u Joint pilot project as part of CMS / California DHCS Medi-Cal 2020 Demonstration Project

u EMS-6 collaboration with EMS Base Hospital Physicians to develop prehospital action plans

u Managed clients selected for highest utilization

u Care Coordination Conferences held weekly

u Primary care providers and nursing

u Social Workers, Case Managers

u Prehospital action plan

u List of resources available for client

u Requires on-scene evaluation by EMS-6

u Does not replace emergency care

Pre-hospital action plan developed

Paramedic Attitudes toward Sobering Centers

u Survey of 297 SF Paramedics

u Frustration with challenging patient population

u Moderate concern for bad patient outcome from transport decision (36% agree)

u NOT concern for clinical care at sobering center (70% disagree)

u NOT lack of interest in patient population (64% disagree)

EMS “Must Haves”

u Clear protocols and policies (66% agree)

u Support from EMS agency (74% agree)

Paramedics: Important factors

u Belief that sobering center has additional resources beyond ED (60% agree)

u Belief that patient outcome will be improved (63% agree)

u Belief that sobering center is a safe place (58% agree)

Safety of EMS triage to Sobering?

u 2003-2017: >50,000 encounters, 12,500+individuals

u Analyzed SF Sobering Center July 2013 – June 2016

u 10,980 total encountersu 4,045 (37%) triaged by EMS

u 4.2% secondary transport to ED

u Most common reasons for secondary transfer: tachycardia, alcohol withdrawal

Smith-Bernardin SM, Kennel M, Glenn M, Yeh C. EMS Can Safely Transport Patients to a Sobering Center as an Alternate Destination. Ann Emer Med. October 2017. 70:4 (S92)

Challenges

u Community Paramedicine and Alternate Destination legislative challenges

u Improving utilization of SF Sobering Center as EMS Destination

u Improve notification of EMS-6 for high user field contact