Thanks to a California Senate bill, starting in January 2019, it became mandatory that all hospitals in the state develop a plan for safely discharging patients without homes. The law, Senate Bill 1152, has many layers to it, broadly designed to make sure hospitals improve their post-discharge planning for homeless patients—a population segment that is more likely to return to the emergency department (ED) if providers and others don’t help them transition back into the community.
For example, the bill requires hospitals to help homeless patients identify a post-discharge destination and assist in providing transportation to a desired destination within a 30-mile radius. What’s more, in July, another element of the bill went into effect: hospitals now need to provide appropriate behavioral health referrals to other health resources such as community-based organizations, shelters, mental health providers and supportive services.
So far, the bill has been met with mixed reaction amongst state healthcare leaders who are motivated to improve California’s homelessness crisis—approximately half a million Americans are without homes, with about one-fifth of them in California—but who at the same time need more resources at hand to comply with the law.
One such leader is Ronn Berrol, M.D., the emergency department medical director at Alta Bates Summit Medical Center in Oakland, Calif. Before it got cancelled, Berrol was scheduled to present at the annual HIMSS conference this week on how his organization, and the broader community, are leveraging resources to help navigate the state’s homelessness crisis. Berrol recently spoke with Managing Editor Rajiv Leventhal about these critical healthcare issues. Below are excerpts of that discussion.
Can you describe the impact of homelessness on hospital ED resources?
We have known that [homelessness presents] a great challenge in healthcare, as the homeless tend to have high ED frequency usage. They have complex patient care needs and chew up a lot of resources. Once [Senate Bill 1152] became a law, it became clear that we had to find another way to start to identify the homeless population and then track them. But we only have limited resources [on our own], so if [another organization] is doing some of this work, then we need to share that information on the patient so everyone could be more efficient. That benefits everyone and will likely improve outcomes.
To that end, how has at Alta Bates Summit Medical Center leveraged data and worked with other organizations to meet these goals and comply with the law?
We started using the [care coordination platform from Utah-based technology vendor] Collective Medical as a pilot in 2016, and that was mostly to just understand frequent ED utilizers. Then you [look at the data] and you realize you have someone who comes to your hospital 50 times a year, but they go to another [nearby] hospital 70 times a year, and yet another one 30 times a year.
You then start to realize that someone has likely done some work or testing on this patient that I haven’t done, and maybe they understand the patient better than I do. So rather than each different medical center swimming on their own trying to figure out what they need for that patient and repeating utilization, the whole system works better if we share information. In [the beginning], we didn’t want to waste resources, but then we became mandated by the state to have a discharge care plan for these homeless patients. So, for us, it was about meeting the spirit of the law and not just the letter of it.
How have you improved over time on these care coordination efforts, and what core gaps still remain?
It’s still [a great challenge]. Senate Bill 1152 requires we keep a log of all homeless patients, so we went back and asked ourselves, how are we determining who is homeless? We had to first start recreating our workflow to make sure we really were tracking and understanding our volume of homeless patients. Hospital administrators and those of us in the ED can say we want to know who our homeless patients are, but once it becomes a law then everyone is vested in doing so. And we’re all working together to ask, how are you identifying this? What is happening at registration? What happens when a nurse finds out someone is homeless? If we call a case management consult and they find out someone is homeless, how are we signaling people so we can make sure we are doing all the workflow process we need to?
Also, the [Collective platform] we had been using to track other sorts of high-frequency utilizers was ideal in terms of having a repository to put information in that we could share. We started this pilot with just one other medical center—Highland Hospital, the county hospital here in Alameda. At that time we had no record sharing with this hospital; we just had a glimpse of which patients were going there. We had been working with them for years but never understood their traffic patterns.
But that data is actually easy to collect out of the [Collective tool]. You can get this information from the EHR, but you need different filters and IT support. This [Collective technology] is just answering specific questions; for example, we think these are the patients who are in the high-risk categories and we want to track when they come in. Our [tool] collates that data very quickly.
Once we knew we could filter these patients, we noticed we had one patient coming to our hospital 40 times a year, but the [Collective tool] showed us that this patient, who I never had an ability to talk to Highland Hospital about previously, has been going to their hospital 300 times a year. So our hospital was essentially the getaway for a different environment. Once we understood that, we started making phone calls between the two hospital’s case managers, and while you think that would have happened before, you really need something to push you to do that. So we asked them that if they built a care plan for this patient, who are you following up with? We started talking much more about that patient.
[The problem is that in healthcare], everyone is trying to build a different network of transmitting information and that results in being all over the map at times. So one of our goals is, can we get more people to agree on one way to communicate? For us, the [Collective platform] is that method. We now have a critical mass; we started with just Highland Hospital, but now have 80 percent of the hospitals in the Bay Area putting data into this tool. That becomes very powerful.
The only [big hospital that isn’t on the network] is Kaiser Permanente, who uses Care Everywhere data from Epic, but that [system] doesn’t allow me to get a retrospective analysis of what happened. So if I saw a patient on March 15, and my care team wants to make a complex care plan adjustment on them three weeks later, I only have access to anything happened up until March 15 due to the EHR’s care-sharing agreements. But with the [Collective technology], it allows me to see that the patient had 10 extra hospital visits since that date, for example.
What other benefits have been realized as a result of these coordination efforts?
Anytime you have more people talking to each other, there’s a benefit. This has strengthened our relationships with our FQHCs [federally qualified health centers]. In Alameda County, one thing we have done very well is enroll people in the Affordable Care Act. We have just 1 percent of our population without any healthcare or affordable care. FQHCs have providers and we have a contact person there—a care transition nurse or someone like that—where we can ensure follow-up within a certain period of time. So our ability to schedule appointments that we think will happen, and having someone on the other end receiving those, have been fantastic.
We are beginning to understand and get better data, talk, and communicate more. We have not won the battle but we are going down a road in which we ‘ll continue to improve medical and societal care for this population. This will [serve] as a roadmap for how we handle other types of societal problems. We will take lessons learned on how we used our [care coordination tool]—and how we have collaborated with others and talked to the county hospital more—that will have a significant impact on how we handle other problems.
