• San Francisco General Hospital loses an estimated $3.9 million annually in patient revenues because many Hospital patients require lower levels of care than the care provided by the Hospital. On average, 13 percent of San Francisco General Hospital patients are waiting to be transferred to lower level facilities, and the Hospital receives little or no revenue from third party payers for the higher level of services provided to such patients. By transferring patients to appropriate lower levels of care, San Francisco General Hospital would increase patient revenues by making Hospital beds available for patients requiring higher levels of care.
  
  
• More than 40 percent of San Francisco General Hospital patients who are waiting transfer to lower levels of care are transferred to Laguna Honda Hospital for long term care. Although Laguna Honda Hospital is often near capacity, Laguna Honda Hospital is still able to receive up to five additional San Francisco General Hospital patients per day. San Francisco General Hospital and Laguna Honda Hospital staff need to improve coordination and transfer of patients between the two facilities
  
  
• San Francisco does not have sufficient alternative placements for medical/surgical and psychiatry patients needing levels of care, which are below the level of care provided by Laguna Honda Hospital. On average, San Francisco General Hospital has four medical/surgical and Skilled Nursing Facility patients waiting for alternative placements, representing $692,000 of the $3.9 million, which the Hospital loses annually in patient revenues.
  
  
• The Department of Public Health could cost-effectively fund 8 long-term residential treatment beds and 6 short-term beds providing housing and health care services to patients discharged from San Francisco General Hospital, at an annual cost of approximately $300,000. These increased General Fund costs would be fully offset by increased San Francisco General Hospital patient revenues, resulting from reallocating beds to patients who require the appropriate level of care.

San Francisco General Hospital Utilization Review

San Francisco General Hospital has many patients occupying acute care beds or Mental Health Rehabilitation Facility and Skilled Nursing Facility beds who require a lower level of care. The Hospital foregoes an estimated $3.9 million annually in patient revenues because Hospital beds are not available for other patients.

In FY 2001-2002, thirteen percent of San Francisco General Hospital patients were waiting placement to another facility, as shown in Table 14.1.

Table 14.1

San Francisco General Hospital Patients Waiting Placement to Other Facilities and Associated Costs
FY 2001-2002

Source: Based on data provided by Community Health Network Department of Planning and San Francisco General Hospital Utilization Review

Utilization Case Management

The Hospital’s Utilization Review division is responsible for ensuring that patients are placed at the appropriate level of care, minimizing loss to the Hospital from uncompensated care. Third party payers, including MediCal, Medicare, and private insurers, will "decertify" patients if they determine that the patient does not require acute care hospitalization. Although MediCal pays the Hospital an administrative fee, other payers do not pay the Hospital for decertified days.

The Hospital’s clinical units have developed specific utilization review plans, which apply to all inpatients and admissions, extended stays, and professional services rendered. Under these plans, the Utilization Review nurse manager is responsible for managing daily Utilization Review activities, maintaining utilization statistics, and providing utilization reports to the Performance Improvement and Patient Safety (PIPS) Committee.

The Performance Improvement and Patient Safety Committee consists of at least one physician representative from the Hospital’s clinical and support services. Standing committee members include the administrative directors of quality management and utilization management, the chief nursing officer and Hospital associate administrators. The Performance Improvement and Patient Safety Committee is responsible for:

• reviewing and approving the Hospital utilization management plan,
• facilitating an interdepartmental approach to utilization management, and
• analyzing utilization data to identify utilization trends.

Utilization reports and Performance Improvement and Patient Safety Committee recommendations are provided to the Medical Executive Committee and to the Governing Body/ Joint Conference Committee.

The Utilization Review medical director also serves as chair of the Performance Improvement and Patient Safety Committee, and is responsible for case management quality and decisions.

Utilization Review Case Management

Utilization Review case managers review the status of all patients admitted to the Hospital. This review includes:

• assessing patients’ insurance eligibility and obtaining insurance authorization,
• reviewing medical records documentation,
• initiating and coordinating the discharge planning process in collaboration with the social worker assigned to the services and other health team members,
• completing statistics on patient discharges and conducting retroactive review of the medical record, and
• appealing all cases in which the payer’s refusal to reimburse for service is questionable.

Case managers conduct admission reviews on the first working day after admission to determine if the admission meets the admission criteria for acuity and intensity. By policy, Utilization Review case managers assign a length of stay to patients who meet admission criteria and a review date. If patients do not meet the admission criteria, the case manager notifies the admitting physician that more information is required and monitors the patient’s medical record for updated documentation. The case manager also refers the admission to the Utilization Review medical director to review the medical record for acuity and appropriateness.

Medical/ Surgical Utilization Review Patient Rounds

Nursing administrators conduct Utilization Review patient rounds twice weekly to review the placement status of patients who have been decertified. Utilization Review rounds are intended to identify problems in moving patients from acute medical/surgical beds. The Utilization Review team has a "lower level of care" report, listing the medical/surgical patients who have been decertified, the total length of stay, and the length of stay since decertification. The team goes to each clinical unit to discuss the disposition of the decertified patients. Patients who may be decertified in the future are not included in the "lower level of care" report but are discussed in the Utilization Review patient rounds.

"Below Acute" Medical/ Surgical and Skilled Nursing Facility Patient Days

San Francisco General Hospital daily patient census is made up of many patients who no longer require acute care hospitalization but have not been transferred to a lower level of care. As shown in Table 14.1, approximately 7 percent of medical/ surgical patients and 28 percent of Skilled Nursing Facility patients are waiting for transfer to another facility.

San Francisco General Hospital transfers medical/surgical patients who no longer require acute care hospitalization to the Hospital’s Skilled Nursing Facility (unit 4A), to Laguna Honda Hospital, or to other facilities. Delays in transferring patients to the lower level of care occur if the receiving facility does not have available beds, or if the patient requires psychiatric evaluation. Laguna Honda Hospital often does not accept patients with mental health or behavioral disorders, requiring the Hospital to seek other placements for these individuals.

Utilization Review case managers compile the reasons that patients who are deemed "below acute" occupy acute medical/surgical bed, as shown in Table 14.2.

Table 14.2

Major Reasons for "Below Acute" Medical/Surgical Patient Days
FY 2000-2001 and FY 2001-2002

Source: San Francisco General Hospital Utilization Review Division

In FY 2001-2002, Utilization Review case managers identified that 33 percent of "below acute" patient days were for patients with no alternative placement:

• For 25 percent of below acute patient days, alternative lower level of care placements (other than Laguna Honda Hospital and the San Francisco General Hospital Skilled Nursing Facility) were not available.
• For 3 percent of below acute patient days, skilled nursing facility placements (other than San Francisco General Hospital) were not available.
• For one percent of below acute patient days, Laguna Honda Hospital did not have available patient beds.
• For 4 percent of below acute patient days, the Skilled Nursing Facility (Unit 4A) did not have available beds.

In FY 2001-2002, case managers identified an additional 15 percent of "below acute" patient days for patients requiring placement in a lower level of care, such as short-term rehabilitation facility or board and care facility. Case managers used this code to identify the first day in which the patient was "below acute" and Hospital staff were seeking alternative placements. For all patient days after the first patient day, case managers designated patients under other codes (such as "no Laguna Honda Hospital or 4A beds available" or "no alternative placement available") if the patients had not been transferred to a lower level of care.

Case managers designated "barriers to discharge: other" for 27 percent of below acute patient days. This code includes all reasons for non-certification that can not be categorized under other codes, When case managers enter the code "barriers to discharge: other" into the information system, they also specify the reason. The Utilization Review nurse manager reviews the reasons for the "barriers to discharge: other" and identifies patterns, if present.

Administrative and Non Covered Days

Third party payers do not reimburse San Francisco General Hospital for below acute patient days for patients occupying acute medical/surgical beds. MediCal will pay the Hospital an administrative fee of $218 per day, which is $857 less than the MediCal per diem rate of $1,075 per day, for below acute patient days. Other payers do not reimburse the Hospital for these days.

As noted in Chart 14.1, the percent of non-covered acute medical/surgical days has increased in the past two fiscal years.

Chart 14.1

Increase in Percentage of Non-Covered Medical/Surgical Patient Days
FY 2000-2001 through FY 2001-2002

Source: San Francisco General Hospital Utilization Review data for acute care inpatients. This data excludes Psychiatry, the Mental Health Rehabilitation Facility, and the Skilled Nursing Facility (4A).

Acute Psychiatry and Mental Health Rehabilitation Facility Patient Flow

On average, 14 percent of patients in acute psychiatry beds and 17 percent of patients in the Mental Health Rehabilitation Facility were waiting for placement in a lower level of care.

During FY 2001-2002, the San Francisco General Hospital Psychiatry division implemented policies to improve patient flow to the appropriate level of care.

Bridge Committee

San Francisco General Hospital established a Bridge Committee in 1999 to identify patients who were difficult to place and possible placements. The Bridge Committee was made up of staff from Community Mental Health, San Francisco General Hospital Social Work department, Utilization Review, and Laguna Honda Hospital. Between July 1999 and May 2002, the Committee reviewed and identified placements for 52 individuals requiring long term and specialized care. Many of these patients had been refused admission to Laguna Honda Hospital for behavioral or other reasons. In several instances, the Department of Public Health provided patch monies to place these patients in other facilities.

Mental Health Patient Care Coordinator

The Bridge Committee was terminated when the Department of Public Health created a nursing position to coordinate psychiatry patient placements in March 2002. The role of the patient coordinator is to identify community placements for Hospital patients prior to discharge, including alternative placements if the first choice placement is not available. The patient coordinator works daily with Hospital Social Work and Utilization Review staff to identify patients requiring special placements on discharge. Although the patient coordinator position is intended to work primarily with psychiatry patients, the coordinator also identifies placements for medical/surgical patients with behavioral problems, Laguna Honda Hospital patients and jail patients.

After establishing the placement coordinator position in March 2002, San Francisco General Hospital psychiatry inpatient administrative days declined by 55 percent compared to the prior year. Psychiatry administrative days from March 1, 2002 to April 30, 2002 were 214 less than the same period in 2001. Psychiatry administrative days from May 1, 2002 to June 15, 2002 were 1,130 less than the same period in 2001. Patient census and types of patients remained largely the same between FY 2000-2001 and FY 2001-2002, and San Francisco General

Hospital attributes the reduction in psychiatry administrative days to improved patient flow.

Table 14.3

Comparison of Acute Psychiatry Administrative Days
FY 2000-2001 and FY 2001-2002

Source: Department of Public Health Community Mental Health

Transferring Patients to a Lower Level of Care

San Francisco General Hospital has a large number of patients who should be transferred to a lower level of care. In the medical/surgical and psychiatry nursing units, many patients occupy acute care and skilled nursing care beds while waiting for appropriate placements in lower levels of care.

Transferring Medical/Surgical Patients to a Lower Level of Care

Medical/surgical patients who no longer require acute care hospitalization but require some form of ongoing care can be transferred to San Francisco General Hospital’s Skilled Nursing Facility (unit 4A), to Laguna Honda Hospital, or to another facility. San Francisco General Hospital places only short-term rehabilitation patients or patients who have been approved but not yet transferred to Laguna Honda Hospital on unit 4A. San Francisco General Hospital refers patients requiring longer-term care to Laguna Honda Hospital, and Laguna Honda Hospital screens the patient for the appropriateness of the referral.

Transferring Medical/Surgical patients to the Skilled Nursing Facility

Patients who require short term rehabilitation or who have been approved for transfer to Laguna Honda Hospital but who are awaiting an available bed can be transferred to San Francisco General Hospital’s Skilled Nursing Facility, unit 4A.

Demand for medical/surgical patients to transfer to the Skilled Nursing Facility (Unit 4A) has been high, exceeding the number of available beds. Prior to FY 2002-2003, San Francisco General Hospital budgeted for 20 Skilled Nursing Facility beds. The 4A census, however, has consistently exceeded 20 patients, and in FY 2002-2003, San Francisco General Hospital increased the number of budgeted beds to 28. Prior to FY 2002-2003, the Hospital admitted more than 20 patients to 4A if sufficient staff were available for the higher census.

Transferring Patients to Laguna Honda Hospital

Most San Francisco General Hospital patients who require a lower level of care are referred to Laguna Honda Hospital. Approximately 40 percent of Laguna Honda Hospital patients are admitted from San Francisco General Hospital. Both San Francisco General Hospital and Laguna Honda Hospital staff are responsible for evaluating patients for transfer from San Francisco General Hospital to Laguna Honda Hospital.

In FY 2001-2002, Laguna Honda Hospital implemented an informal policy to screen San Francisco General Hospital referrals daily rather than at the weekly screening committee meeting. By policy, San Francisco General Hospital referrals have priority for admission to Laguna Honda Hospital.

The San Francisco General Hospital demand for patient beds at Laguna Honda Hospital often exceeds the number of available beds. On average, approximately nine San Francisco General Hospital patients are approved for transfer to Laguna Honda Hospital but are unable to transfer, as shown in Table 14.4. Additionally, another five to six patients have been referred to Laguna Honda Hospital but have not yet been approved for transfer.

Table 14.4

Average Number of Patients Approved for Transfer to Laguna Honda Hospital and Average Number of Days Waiting for Transfer, by Clinical Unit
FY 2001-2002

* Weighted Average
Source: San Francisco General Hospital patient census data. The data regarding waiting time is from November 23, 2001 through July 4, 2001, a seven-month period.

Our review of San Francisco General Hospital data regarding patients approved and waiting for transfer to Laguna Honda Hospital shows that Laguna Honda Hospital had available beds to receive San Francisco General Hospital medical/surgical patients much of the time. In FY 2001-2002, Laguna Honda Hospital had a daily average of approximately five beds available to accept San Francisco General Hospital transfers, of which four beds were in the admitting unit (unit M-5). Although Laguna Honda Hospital can not receive all patients waiting for transfer, Laguna Honda Hospital frequently has the capacity to admit up to five San Francisco General Hospital medical/ surgical or Skilled Nursing Facility patients who have been approved for transfer.

According to San Francisco General Hospital and Laguna Honda Hospital staff, patient-specific issues, such as a change in the patient’s medical condition, can prevent the transfer of San Francisco General Hospital patients to Laguna Honda Hospital, even when beds are available. However, both San Francisco General Hospital and Laguna Honda Hospital staff have acknowledged that improved coordination between the two hospitals could facilitate transfers.

Once the patient’s physician has determined that a patient is medically able to transfer to a lower level of care, several different San Francisco General Hospital and Laguna Honda Hospital staff are responsible for implementing the transfer:

• Utilization Review staff assess and determine when a patient is ready for placement at a lower level of care, and coordinate transfer to Laguna Honda Hospital.
  
  
• Laguna Honda Hospital staff refer patients for physician screening, including psychiatric screening, and notify San Francisco General Hospital of placement decisions. Laguna Honda Hospital staff determine available beds and coordinate with San Francisco General Hospital to transfer patients.
  
  
• Department of Social Work staff initiate the transfer of the patient to Laguna Honda Hospital.

Problems in patient transfers can occur at any point in the process. San Francisco General Hospital should develop specific performance measures for each step in the process of evaluating and coordinating patients for transfer to Laguna Honda Hospital. The Hospital should develop a checklist for each patient, identifying the steps and associated performance measures in the transfer process, and documenting any variations from the measures. These checklists should be compiled and evaluated monthly, to identify performance measure variations and the reasons for the variations, and to recommend improvements in the process.

Transferring Patients to Alternative Facilities

Although San Francisco General Hospital has implemented policies and procedures to closely manage patient disposition, the number of decertified patients in acute care beds has not declined over the prior two years. According to San Francisco General Hospital staff, San Francisco does not have sufficient alternative placements for Hospital medical/surgical and psychiatry patients needing a lower level of care, especially for levels of care below Laguna Honda Hospital’s level of care.

Medical/Surgical Patients Requiring Lower Levels of Care

In FY 2001-2002, approximately 19 percent of medical/surgical and Skilled Nursing Facility patients were waiting for alternative placements which offer levels of care below Laguna Honda Hospital. On average, four medical/surgical and Skilled Nursing Facility patients were waiting for placement in community, long term care or other facilities.

Table 14.5

Medical/Surgical and Skilled Nursing Facility Patients Waiting Placement in Lower Levels of Care,
September 13, 2001 through July 5, 2002

Source: Community Health Network Department of Planning

Placement Options for San Francisco General Hospital Patients within the Department of Public Health

San Francisco General Hospital delays discharge for many patients because alternative placements are not available. Many Hospital patients require additional medical or mental health care but are unable to find appropriate placements because of their special needs, including housing needs. The Department of Public Health currently has the Housing and Urban Health Program, which provides supportive housing and health care services to homeless and disabled persons.

The Housing and Urban Health Program has three facilities, providing services to patients discharged from San Francisco General Hospital.

• The Windsor Hotel provides 16 beds for individuals discharged from San Francisco General Hospital who need short term housing and health care services for up to 90 days. General Fund monies pay for the Windsor, although Windsor Hotel clients pay a portion of the monthly housing costs. Windsor Hotel support services are managed by the Tom Waddell Health Center and are partially reimbursed by Federally Qualified Health Center (FQHC) funds.
  
  
• The Broderick Residential Care Facility is a 34-bed State-licensed long-term residential care facility for individuals who are difficult to place due to behavioral or medical problems. The Broderick Residential Care Facility receives individuals transferred from the Mental Health Rehabilitation Facility, Laguna Honda Hospital, and from San Francisco General Hospital medical/surgical units. The Broderick Hotel receives mostly General Fund monies. Although the Broderick Residential Care Facility does not qualify for the MediCal per diem rate paid to freestanding nursing facilities, the Broderick Residential Care Facility does receive approximately $170,000 annual MediCal reimbursements designated for mental health providers.
  
  
• The Keene Hotel has 20 units for short term housing up to 14 days for individuals discharged from San Francisco General Hospital. The Department pays $600 per unit per month plus $70,000 annually for one staff person to provide services, such as guaranteeing that residents attend follow-up clinic appointments. General Fund monies fund the Keene Hotel program.

Two studies conducted by the Department of Public Health suggest that supportive housing decreases demand on services provided by San Francisco General Hospital. One study found that medical/surgical and psychiatric admissions were reduced by approximately 45 to 49 percent for patients in supportive housing compared to the period before they entered supportive housing. Another Department study of 22 individuals who were placed in the Broderick Residential Treatment program projected $721,324 in General Fund savings in reduced Skilled Nursing Facility, Mental Health Rehabilitation Facility, and acute hospitalization costs.

Census data provided by San Francisco General Hospital shows that from FY 1997-1998 through FY 2001-2002, homeless individuals comprised 17 to 18 percent of the Hospital inpatient census and 8 to 9 percent of the outpatient census. The larger percentage of homeless individuals in the Hospital inpatient population compared to the outpatient population suggests that homeless individuals are hospitalized proportionally more than other individuals using San Francisco General Hospital services. Although the San Francisco General Hospital policy is to discharge patients to the streets if they are medically able to be discharged, Hospital staff do not consistently implement this policy.

Costs of Funding New Residential Treatment Facility Beds and Offsetting Reductions in Foregone San Francisco General Hospital Revenues

If the Department of Public Health were to fund additional beds to provide housing and health care services, San Francisco General Hospital patients waiting for alternative placements could be discharged more quickly. Although funding new supportive housing beds would result in new General Fund costs, these costs would be offset by reductions in foregone San Francisco General Hospital revenues and by improved allocation of San Francisco General Hospital resources. By transferring patients who require a lower level of care to alternative facilities, San Francisco General Hospital could re-allocate beds and increase third party reimbursements.

Currently, the Broderick Residential Treatment Facility allocates:

• 12 beds to Laguna Honda Hospital patients,
• 5 beds to San Francisco General Hospital medical/surgical patients, and
• 16 beds to the Hospital’s Mental Health Rehabilitation Facility patients.

On average, from January 2002 through June 2002, the number of patients waiting for residential treatment facility placement were:

• 6 Mental Health Rehabilitation Facility patients, with an average wait time of 68 days, and
• 4 to 5 Laguna Honda Hospital patients.

For the same period, one acute psychiatry patient was waiting for transfer to the Mental Health Rehabilitation Facility, which had a full census.

To meet this need, the Department of Public Health could cost-effectively fund eight new beds. These beds would primarily serve patients discharged from the Mental Health Rehabilitation Facility. As shown in Table 14.6, if the Department of Public Health funded eight new residential treatment beds, the Department of Public Health’s increased costs for the new residential treatment beds would be offset by increased patient revenues to San Francisco General Hospital. If patients requiring a lower level of care were transferred to residential treatment beds, Mental Health Rehabilitation Facility beds would become available for patients with third party reimbursement, increasing revenues to the Hospital.

Table 14.6

Estimated Annual Cost to Fund Eight New Residential Treatment Beds and Estimated Potential San Francisco General Hospital Revenue from Increased Patient Reimbursements

Source: Based on data provided by the Department of Public Health Housing and Urban Health Program

The Department of Public Health could possibly achieve additional cost savings by funding additional residential treatment beds for placing Laguna Honda Hospital patients. An increase in available Laguna Honda Hospital beds would allow San Francisco General Hospital to increase transfers to Laguna Honda Hospital, resulting in cost savings from reduced decertified patient days.

Costs of Funding New Housing and Health Care Services and Offsetting Reductions in Foregone San Francisco General Hospital Revenues

The Windsor Hotel provides housing and support services for up to 90 days for patients discharged from San Francisco General Hospital. The Hotel provides on-site physician, nursing, and psychiatric social work services to homeless clients, and is designed to provide respite care until newly discharged patients are medically stable. Currently, the Windsor Hotel has 16 short-term beds for San Francisco General Hospital patients. In FY 2001-2002 San Francisco General Hospital had an estimated 6 patients daily in the acute medical/surgical and psychiatry clinical units, and the Skilled Nursing Facility (4A), waiting for community placements. The Department of Public Health could cost-effectively fund six new housing and health care services beds. The estimated net cost of these six beds is $98,931. These Department of Public Health costs would potentially be offset by increased San Francisco General Hospital patient revenues from appropriate allocation of Hospital beds.

Table 14.7

Estimated Annual Cost to Fund Six New Beds to Provide Housing and Health Services and

Estimated Potential San Francisco General Hospital Revenue from Increased Patient Reimbursements

Source: Based on data provided by the Department of Public Health Housing and Urban Health Program

Obtaining MediCal Waivers to Fund Supportive Services

Although MediCal pays per diem payments for patients transferred to freestanding nursing facilities, MediCal does not pay for the cost of providing supportive housing services to patients discharged from San Francisco General Hospital. The Housing and Urban Health Program has considered seeking a MediCal waiver to provide funding for supportive housing services. Section 1915(c) of the Social Security Act allows states to apply for Medicaid waivers to provide alternatives to institutional care for the disabled. The 1915(c) waiver, known as the "home and community-based services" waiver, allows states to cover services not traditionally covered by Medicaid payments. San Francisco would need to apply through the State to obtain the 1915(c) waiver. Currently, the State has six existing 1915(c) waiver programs although none provide supportive housing services.

To qualify for a 1915(c) waiver, San Francisco and the State would need to show that the supportive housing program would be cost-effective. Under Federal requirements, the proposed program can not cost the Federal government more than the expected Medicaid costs to provide traditional services. Obtaining a waiver may be difficult. Recent changes to the California Welfare and Institutions Code require the State to explore a waiver to provide MediCal payments for assisted living services. According to the Corporation for Supportive Housing, supportive housing services may qualify for an assisted living waiver, if approved by the Federal Medicaid program. However, whether the State can successfully achieve a 1915(c) waiver for assisted living programs and whether the Housing and Urban Health program would qualify is not certain.

Conclusion

San Francisco General Hospital has many patients who require a lower level of care. The Hospital foregoes an estimated $3.9 million annually in patient revenues because Hospital beds are not available for other patients.

Although San Francisco General Hospital has implemented policies and procedures to monitor and transfer patients to a lower level of care when appropriate, the number of decertified and non-covered days has not decreased. Forty percent of San Francisco General Hospital patients who transfer to an alternative placement transfer to Laguna Honda Hospital for long term care. Although Laguna Honda Hospital is often near capacity, Laguna Honda Hospital is still able to receive up to five additional San Francisco General Hospital patients daily. San Francisco General Hospital and Laguna Honda Hospital staff need to improve coordination and transfer of patients between the two facilities.

San Francisco does not have sufficient alternative placements for Hospital medical/surgical and psychiatry patients needing a lower level of care, especially levels of care below the level of care provided by Laguna Honda Hospital. On average, four medical/surgical and Skilled Nursing Facility patients are waiting for alternative placements representing $692,000 of the $3.9 million, which the Hospital loses annually in patient revenues.

Many San Francisco General Hospital patients require some level of care after discharge but do not have an alternative placement. Often, Hospital patients are homeless.

The Department of Public Health has a Housing and Urban Health program to provide housing and health services to homeless and disabled individuals. Currently, the Housing and Urban Health program has some beds designated for San Francisco General Hospital patients. The Department of Public Health should fund additional beds to provide temporary and long term services to patients discharged from San Francisco General Hospital. San Francisco General Hospital would achieve increases in third party reimbursements by reallocating beds to patients who require a higher level of care, which would offset increased costs to fund additional beds.

Recommendations

The Department of Public Health should:

Costs and Benefits

The Department of Public Health would incur increased General Funds costs of approximately $204,608 to fund eight new residential treatment facility beds and $98,931 to fund six new housing and health services beds. Increased San Francisco General Hospital patient revenues would potentially offset these increased General Fund costs, totaling $303,539. By transferring patients who no longer require the level of care provided by San Francisco General Hospital to these new residential treatment facility and housing and health services beds, the Hospital could allocate beds to patients with third party reimbursements.

Additionally, based on a further 5 percent reduction in the average number of patients per day awaiting placement due to improved utilization management and transfer of non-acute patients to lower levels of care, we estimate that San Francisco General Hospital would achieve approximately $195,000 annually in additional savings.

1. Estimated costs are based on (a) the estimated patient days for each service that patients were waiting for alternative placements, (b) estimated payer mix (MediCal, Medicare, commercial, and unsponsored), (c) and estimated lost revenue to the Hospital based on payer source.
2. The Federal Medicaid program will provide federal matching funds for some rehabilitation services. In 1991 California included mental health rehabilitation services in the MediCal rehabilitation program.
3. "Evaluation of the Impact of Supportive Housing on Hospital and Emergency Room Use in San Francisco", Tia Martinez, Goldman School of Public Policy, University of California
4. This estimate may understate the actual number of homeless individuals because the data is obtained from the patient's admission record. The Hospital has proposed conducting a one-day study of the patient population, using a broader definition of homelessness, to determine the actual homeless patient population.