Social Emergency Medicine
Background: In San Francisco county, people who frequently use emergency and urgent services across different settings (i.e., medical, mental health, and substance use disorder services) are referred to as high utilizers of multiple systems (HUMS). Many studies have described frequent emergency department (ED) users, but few have evaluated high utilization across these multiple domains. We developed a scoring system to identify the top 100 HUMS patients based on emergent/urgent service use in San Francisco county, and characterized this population in order to develop county-wide interventions to better coordinate their care.
Methods: We used the Coordinated Care Management System (CCMS), San Francisco county’s integrated data system that contains housing, jail, health and behavioral health encounters, and the Emergency Department Information Exchange (EDie), to identify and characterize the top 100 HUMS patients in San Francisco county for the 2017 – 2018 fiscal year. We calculated utilization scores based on nine different types of urgent and emergent medical, mental health, and substance use services: ED and urgent care visits, medical and psychiatric hospitalizations, psychiatric emergency services, psychiatric urgent care clinic visits, medical and social detoxification and sobering center stays.
Results: 99 of the Top 100 HUMS had a history of homelessness and 57 of the 100 were unsheltered (living outdoors) at their last point of contact with services. On average, these patients had 130 emergent/urgent service visits or stays per year (min = 69, max = 346) and accessed four of the nine different urgent/emergent service types. The medical ED was the by far the most frequently visited service – 99 of the 100 had at least one ED visit, with a mean of 89.2 visits per year – followed by the sobering center (24.6 visits per year) and psychiatric emergency services (7.9 visits per year).
Conclusion: The highest utilizers of multiple systems in San Francisco have high social needs and experience fragmented care. Commonly-visited health care settings such as the ED represent a potential point of outreach and intervention for these patients.