The sole public safety net hospital in the city, San Francisco General Hospital (SFGH) serves a diverse population, of which 30 percent are uninsured. Here, Michelle Schneidermann, MD, outlines five factors that make care transitions challenging for SFGH patients and that helped to drive creation of a Care Transitions Task Force.
On any given day, around 8 to 10 percent of our inpatients are considered to be homeless. This is a population that is generally at higher than average risk for readmission stemming from a variety of factors. These include social determinants of health, like poverty and housing instability, comorbidity such as mental illness and substance use, and limited access to services in the face of complex care needs.
For the past ten years or so, there have been varied but somewhat siloed efforts to reduce post-discharge adverse events and improve the quality and safety of care transitions. In early 2012, as we approached the onset of Medicare’s readmission penalties, we had a coming-late-to-the-party-’aha’ moment, where we recognized the need to tackle care transitions and readmissions in a more structured and coordinated way.
Specifically, we recognized the need to create a comprehensive care transitions program to provide patients with the proper care and tools to stay out of the hospital. We needed to bridge those varied siloed programs by connecting them. Also, we wanted to provide a centralized clearinghouse or access point of information for the network on care transitions, and standardize and improve processes of care.
We decided, in retrospect, somewhat arbitrarily, that our aim would be to reduce readmissions by 15 percent over two years. These unmet goals led us to charter the San Francisco Health Network Care Transitions Task Force in the fall of 2012.
Dr. Michelle Schneidermann completed her primary care internal medicine training at UCSF and joined the UCSF faculty in 2003, where she is a member of the Division of Hospital Medicine at San Francisco General Hospital (SFGH). Through her inpatient clinical work and work with ambulatory programs, she has been able to directly witness the successes and challenges of patients’ transitions and generate feedback to the providers and systems that manage their care.
At SFGH, Dr. Schneidermann leads the Care Transitions Task Force, a cross-continuum, multidisciplinary team charged with improving the quality and safety of care transitions as well as reducing preventable readmissions.