SF General and UCSF: Partners in Public Health
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| Sue Carlisle |
- • The School of Dentistry operates the UCSF Oral and Maxillofacial Surgery Clinic, which provides inpatient and outpatient services such as trauma surgery for the jaw and facial bone fractures, surgical correction of maxillofacial skeletal and soft tissue deformities and diagnosis and disease.
- • The School of Nursing offers a nurse-midwifery education program that has graduated hundreds of nurse-midwives and has provided more than 12,000 women with midwifery care for their births, about half of which are at SFGH.
- • The School of Pharmacy manages the California Poison Control Center, which consists of four answering sites, including SFGH. The school's Betty Dong also regularly works with a multidisciplinary team of pharmacists, physicians and nurse practitioners to answer calls to the National HIV Telephone Consultation Service and the National Clinicians Hotline.
As the City and County of San Francisco's acute care hospital, SFGH is the primary provider of safety-net health care for the most vulnerable - the poor, uninsured working families, immigrants and the elderly. About 80 percent of its patient population either receives publicly funded health insurance (Medicare or Medi-Cal) or is uninsured. The number of uninsured people in San Francisco has climbed to 150,000 - all of whom are welcome at the public hospital. SFGH also cares for the homeless, who make up about 8 percent of its patients. "There are so many things woven into the fabric of the values of this hospital that I forget it's not that way everywhere else," says Susan Scheidt, who works in psychosocial medicine. SFGH is known for its patient-centered care and communication - efforts recently honored by the American Medical Association. It excels in reducing the financial, linguistic, cultural, physical and operational barriers to health care. Among its many patient-friendly features are staff who are trained and tested to interpret 20 different languages, an advocacy office located in the lobby that helps patients navigate the hospital, and an immigrant and refugee clinic that houses the Newcomers Health Program to provide access to health care. Pediatric Asthma Clinic. SFGH is open to innovation and ideas that break the mold and set new standards for a public hospital. "If you have the energy and time commitment to do something, people will allow you to do it," says Gene O'Connell, executive administrator at SFGH. When Bill Schecter, chief of surgery at SFGH, saw the need to provide outpatient surgeries for the low-income residents who otherwise would not be able to afford them, he co-founded Operation Access in 1993. He and other staff members work weekends alongside students and residents who volunteer for this program. Operation Access is now a Bay Area-wide organization. For this public service, Schecter has won the American Medical Association's 2006 Pride in the Profession Award. Similarly, when infectious disease epidemiologist David Bangsberg saw that HIV-positive Ugandans couldn't afford the drug regimen, he started the Family Treatment Fund to provide them with antiretroviral treatment. {pagebreak}
Historic Partnership
Thanks to the foresight of city and University pioneers, SFGH and UCSF have enjoyed a historic and heroic partnership, which was first made official in an 1873 affiliation agreement. When the partnership was formalized again in 1959, Director of Public Health Ellis D. Sox said the agreement guaranteed that patients "would receive the best possible care." Today, more than 2,000 UCSF employees work alongside 3,000 SFGH employees to provide a full range of patient care services at SFGH. More than 160 principal investigators conduct research through programs based at the SFGH campus with an annual budget of more than $83 million - money allocated by federal and state grants and private and corporate donations. SFGH offers a valuable training ground, serving diverse patients with some of the city's most complex and chronic problems, including HIV, homelessness and substance abuse. It provides distinct services such as a high-level trauma center and the city's busiest emergency department, as well as inpatient, outpatient, diagnostic, psychiatric and rehabilitation services for adults and children. In addition, SFGH has the only psychiatric emergency service in the region. Serving some 100,000 people a year, SFGH is the main provider in the Department of Public Health (DPH) Community Health Network, which includes 20 neighborhood clinics. For its part, UCSF contributes the talent and teamwork of its faculty, residents and students who provide high-quality patient care services and conduct cutting-edge clinical and basic research, from pioneering treatment for HIV/AIDS to detecting drug-resistant strains of Staphylococcus. Their groundbreaking discoveries and innovations are often translated into improved health practices, protocols and policies around the world. Trauma CareAs the lead hospital for the San Francisco Emergency Medical Services Trauma System, SFGH provides an important trauma center resource for more than 1.5 million residents of San Francisco and northern San Mateo County. Each year, the trauma team treats more than 3,000 severely injured patients whose bodies may be burned, blasted by gunfire, bruised by assault, or battered from work or vehicle-related accidents. In fact, SFGH operates the city's only level I trauma center - an important destination and designation, for it is the only place equipped with specialized imaging and other instruments and staffed with experts trained and available around the clock to treat the most critically injured patients. The level I accreditation requires SFGH to meet specific standards of care, including availability of anesthesiologists, surgeons and nurses specializing in trauma care; other specialists such as cardiac, orthopedic, oral, hand, spine and neurological surgeons; and radiology and respiratory therapists. The designation also requires SFGH to conduct clinical research to advance the care of patients with life-threatening injuries. Mexican artist Frida Kahlo is among the most famous patients to be treated by the trauma experts at SFGH. As the story goes, Kahlo valued the patient-centered care she received at SFGH. In appreciation, she painted a portrait in tribute to her doctor. That painting - and one of women making tortillas, done by her famous husband, Mexican artist Diego Rivera - now is on exhibit in the lobby at SFGH. Kahlo symbolizes the multicultural community that has depended on the hospital for more than a century. Like Kahlo, more than half of all trauma patients who arrive at SFGH have one or more fractures. In fact, an unrelenting demand for orthopedic surgeons and other specialists has put an extraordinary amount of pressure on SFGH to recruit and retain the best in their fields. And while attracting them to the academic medical center for training and research is easy, keeping them employed on staff is more difficult. {pagebreak}
Emergency Epicenter
The front line of emergency care in the city, SFGH's Emergency Department (ED) team will be the first to cope with any type of manmade or natural disaster. On a typical day, the ED is transformed into a hectic, fast-paced setting where patients are triaged, with the sickest being treated first. Last year, 65 percent of the hospital's inpatients were evaluated, treated and admitted through the ED. That's high, compared with other hospitals nationally, for which about 25 percent of admissions originate from their EDs. SFGH's high admission rate is due to the severity of patient illness, its designation as a trauma center and the lack of primary care accessed by their patients. But even as the pace in the ED speeds up - largely due to patients suffering from drug overdoses, crime- or work-related injuries, and traffic accidents - the ED at SFGH has seen a marked decrease in its patient census. A key measure of volume is the hospital's diversion rate, the times when it signals to ambulances to divert patients away to other hospitals due to overcrowding in the ED. In January 2001, SFGH was on divert status 44 percent of the time - an all-time high - compared with 18 percent in 2006, according to Alan Gelb, clinical professor and chief of the Emergency Department at SFGH. Gelb points to three significant improvements that have lowered the diversion rate. First, SFGH opened the Integrated Soft Tissue Infection Service (ISIS) clinic, where patients with infections such as abscesses can be treated. Second, it expanded hours at the urgent care clinic, which operates 12 hours a day, seven days a week, treating about 20,000 patients a year and thereby reducing visits to the ED. And third, under the leadership of CEO O'Connell, the hospital is discharging sooner patients who are capable of being cared for in other, less expensive rehabilitation and skilled nursing facilities, Gelb says. Despite fewer patients, the wait to be seen in the ED and to get a hospital bed can still be long, Gelb says. It can take up to eight hours for non-critical patients to be seen in the ED, depending on the time of day and the severity of a patient's illness. Designed and constructed in 1976 to serve a maximum of 40,000 patients a year, the ED now sees more than 55,000, according to Gelb. The gridlock in the ED means that some patients have to lie on gurneys in the hallways until they get a hospital bed and that there are delays in surgeries. "The average wait time for a patient to go to a (non-Intensive Care Unit) room after they have been admitted from the ED is five to 10 hours, also depending on the severity of illness," says Gelb, a graduate of the UCSF School of Medicine who joined the UCSF faculty in 1980. "Unfortunately, this is not unique at SFGH, but is common across the country." "The main solution is to have more inpatient beds available and staffed by RNs," Gelb says. "The desire to lower overhead costs and the national nursing shortage make it difficult to accomplish this. The system has already gained as much as it can by keeping people out of the hospital that may be able to fare well at home." In addition to treating medical and surgical emergencies, SFGH serves as the city's receiving hospital for psychiatric patients. More than 7,000 troubled patients with mental illness are brought to the psychiatric emergency service each year, 40 percent of whom are ultimately admitted to some of the department's 100 psychiatric inpatient beds. "Over the last decade, many other hospitals have either closed their psychiatric units or decided to not to take MediCal psychiatric patients any longer," says Robert Okin, chief of psychiatry and professor of clinical psychiatry. "The result is that the psychiatric inpatient units at SFGH have become the city' mainstay for acute psychiatric patients." To help psychiatric patients avoid inpatient hospitalization when possible, and to help stabilize them after they leave, Okin created intensive case management programs consisting of multidisciplinary teams that help patients find housing, obtain financial entitlements, monitor their medications daily, and link them with medical services, outpatient mental health care, and substance abuse services. The result has been a dramatic decrease in the number of patients needing repeated inpatient care and being arrested for petty crimes. "One of the most important challenges is how to keep very volatile psychiatric patients stable in the community and how to help them create meaningful lives," Okin says. "Our case management programs have accomplished this for hundreds of patients." Ongoing ChallengesSFGH also faces other challenges common in the health care industry across the US. Mounting pressures and problems include the growing number of uninsured, the nursing shortage, time constraints to treat patients, inaccessibility to primary care providers, an inadequate supply of staffed hospital beds, rising health care costs and declining reimbursements for services. Financial support for SFGH has not kept pace with increased costs of health care, which jeopardizes the academic medical center's quality of care and teaching and reduces the hospital's ability to recruit and retain health care professionals. In fact, physicians of all kinds, primary care doctors, psychiatrists and anesthesiologists, cite below-market salaries in an expensive city, burnout from being on call for trauma coverage and sometimes inadequate administrative-academic support as reasons for leaving. The nationally mandated resident work hour restrictions have also resulted in fewer trainees being available to share the workload. As a result, SFGH is in an extremely fragile condition, Carlisle says. Of SFGH's operating budget of $465 million, about 80 percent comes from payments from Medi-Cal, Medicare, other insurance plans, and directly from patients for care delivered by UCSF physicians and allied health care professionals. Less than 20 percent of SFGH's budget comes from the city's general fund. Consequently, unlike some public health services, SFGH generates revenue: For every 21 cents allocated from the city's general fund, the hospital receives 79 cents from other sources, such as federal programs and third-party health care payers.
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| Talmadge King |
Turning Point
That may change, now that the DPH established a steering committee charged with guiding the budget priorities and with identifying and developing initiatives that work to benefit the entire public health care system. King serves on that committee, which is made up of other senior administrative and clinical leaders from the city's health care delivery system, including DPH Director Mitch Katz and SFGH's O'Connell, both of whom have been advocates for SFGH. The committee will make recommendations to the San Francisco Health Commission prior to the city budget being finalized. For his part, Mayor Gavin Newsom has pledged more financial support for public health. In fact, the Mayor announced on Feb. 7 the formation of a Universal Health Care Council to develop a proposal to provide health care for all uninsured San Francisco residents. He also proposed investing $51.6 million in the city's health care system, which includes $25 million for the pre-development phase for a new hospital, which must be built to meet a state seismic safety law. This money would allow SFGH to move forward with architectural design and engineering plans, among other steps. That's good news for SFGH.
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| Kevin Grumbach |