ED Care Coordination Task Force

In healthcare systems, a priority is to provide high-value and cost-effective medical care, including an infrastructure to ensure seamless and cohesive care coordination for patients.

The patient volume at San Francisco Health Network (SFHN), especially in the ED, has steadily increasing.

This may be due to poor access to care, patients going to an inappropriate level of care compared to their low-acuity medical needs, and under-utilizing of other available care such as the nurse advice line and urgent care.  Some of this may be attributed to disjointed care coordination, especially for our most vulnerable populations, including non-English speaking, marginalized and jail populations. Frequently, our patients will state that they came to the ED because they did not know if they have insurance or who is their assigned primary care doctor.  Other times, patients will present to the ED after missing their follow-up due to confusion about how to contact their clinic or they did know that for minor complaints, they can call our nurse advice line or go to our urgent care. Furthermore, while the ED is responsible for acute care management, providers frequently find themselves spending a bulk of their clinical time facilitating the next steps for patients once they are discharged. Many of our providers lack the tools and knowledge about how SFHN operates, as well as other SF social services available that would aid in better transitions to the ambulatory setting.

Given the complexity of SFHN system with multiple independent care centers, we having several projects building a comprehensive care coordination system that gets ED patients to their follow-up, improve rate of no-show appointments and reduce costly and redundant ED bounce-backs . The primary goals include using low and high fidelity tools and health implementation science methodologies to  1)Improve education and health system literacy, and 2)Create coordinated patient flow and provider communication systems. By building systems that are cohesive, we can minimize fragmented care and improve the patient’s experience navigating our health system.. We have many cross-functional collaborations and partnerships with different stakeholders and departments throughout the entire SFHN network and San Francisco Department of Health.