SUBJECT
Title
REPORT BACK ON THE RURAL HEALTH POST-HOSPITAL DISCHARGE PILOT PROGRAM (DISTRICT: 2)
Body
OVERVIEW
On March 14, 2023 (6), the Board of Supervisors (Board) directed the Chief Administrative Officer to work with Grossmont Healthcare District to initiate a rural health post-hospital discharge program in Mountain Empire which includes the communities of Boulevard, Campo, Jacumba, Potrero, and Tecate. From July 2020-June 2023, the 30-day unplanned readmission rate averaged 12.1% for rural communities where Sharp Grossmont Hospital was the primary receiving hospital. While Sharp Grossmont Hospital has operated a post-hospital discharge program in more urban communities, no program has existed in rural areas.
County Fire partnered with the Health and Human Services Agency (HHSA), Grossmont Healthcare District, Sharp Grossmont Hospital, Mountain Empire School District, San Ysidro Health, and Southern Indian Health Council, Inc. to establish the pilot program. Launched in June 2023, the pilot program’s medical team includes a County Fire/CAL FIRE paramedic (paramedic) and HHSA Public Health Nurse (Nurse). The Nurse reinforces the hospital discharge medical direction, assists clients with making follow-up appointments with a primary care provider, performs clinical and social assessments, provides case management services, and links clients to the County’s Aging and Independence Services and Self-Sufficiency Services such as In-Home Supportive Services and CalFresh. The paramedic conducts voluntary defensible space inspections, looks for trip hazards and other household dangers, and can initiate an ambulance transport for medically critical patients, as needed. In the first six (6) months of the pilot program, the unplanned 30-day readmission rate has dropped to 4.0% for patients receiving those services compared to 13.9% for those who did not participate and resulted in an estimated cost avoidance of $350,000, when annualized to the Sharp Healthcare system.
Today’s recommendations include receiving a presentation regarding the Rural Health Post-Hospital Discharge program and potential next steps for County staff to make the program permanent or end it after the pilot phase concludes on June 30, 2024.
RECOMMENDATION(S)
CHIEF ADMINISTRATIVE OFFICER
1. Receive a presentation from County staff on the Rural Health Post-Hospital Discharge program.
2. Provide direction regarding funding for the Rural Health Post-Hospital Discharge program.
a. Conclude the program on June 30, 2024, when pilot funds from County Fire, HHSA, and Grossmont Healthcare District end.
b. Direct County staff to work with Sharp Healthcare, Grossmont Healthcare District, health insurance plans, or any other government, healthcare, or non-profit agency, to identify non-County funding to fully support the program and return to the Board if there are any needed actions.
If the Board selects option 2b:
3. Approve and authorize the Clerk of the Board of Supervisors to execute Revenue Agreements, upon receipt, for the Rural Health Post-Hospital Discharge Program including any annual extensions, amendments, and/or revisions thereto that do not materially impact or alter the services or exceed $500,000 annually from Sharp Healthcare, Grossmont Healthcare District, or insurance agencies for the period of July 1, 2024 to June 30, 2029.
EQUITY IMPACT STATEMENT
The Rural Health Post-Hospital Discharge program has supported equitable outcomes in traditionally underserved communities. According to the Health and Human Services Agency Community Health Statistics 2021 Demographics profile, the Mountain Empire region has the highest percentage of population living under the Federal Poverty Level, highest percentage of the population living with a disability, second lowest household income, second highest percentage of senior citizens, and second highest percentage of American Indian/Alaska Native population in our region. A focused program on the health and social needs in Mountain Empire can improve long-term outcomes and support a more resilient population.
SUSTAINABILITY IMPACT STATEMENT
Today’s recommendations support the County’s Sustainability Goal of providing just and equitable access to County services by focusing investment in chronically underserved communities in the Mountain Empire area.
FISCAL IMPACT
There is no fiscal impact associated with today’s actions. However, today’s recommended actions may result in future fiscal impacts, for which staff will return to the Board with funding source identified for consideration and approval.
BUSINESS IMPACT STATEMENT
N/A
Details
ADVISORY BOARD STATEMENT
On May 14, 2023, the San Diego County Fire Protection District Fire Advisory Board received a presentation on the rural health post-hospital discharge follow up pilot program.
BACKGROUND
The Mountain Empire area of San Diego County, which includes the communities of Campo, Potrero, Jacumba, Boulevard, and Tecate, are among the most underserved in our area. This area includes a higher prevalence of tribal members, senior citizens, lower-income residents, Spanish speakers, and individuals who experience several healthcare disparities compared to other communities in our region. The Grossmont Healthcare District is a public agency responsible for contracting with Sharp Healthcare to operate the Grossmont hospital (known as Sharp Grossmont Hospital) and funds public health promotion activities in backcountry communities in the southern portion of the unincorporated area. In 2021, Grossmont Healthcare District established the Rural Health Coalition (Coalition) to convene local leaders, healthcare professionals, County Fire, Health and Human Services Agency (HHSA) staff, and Mountain Empire School District to address needs in the Mountain Empire.
One focus of the Coalition was to remove barriers to health and social care that resulted in 30-day hospital readmissions. From July 2020-June 2023, the 30-day unplanned readmission averaged 12.1% for rural communities where Sharp Grossmont Hospital was the primary receiving hospital. While Sharp Grossmont Hospital has operated a post-hospital discharge program that prioritizes the most urgent medical conditions for in-home visits in more urban communities, no programs have existed in rural areas that provide the same in-home services. One of the challenges of operating a post-hospital discharge program in the backcountry is the small population and long distances to patient homes. For these reasons, the Rural Health Coalition recommended a program that partnered a nurse with a paramedic to engage with patients discharged from the hospital to seek to address patient’s holistic needs, along with treatment plan compliance. On March 12, 2023 (6), the Board of Supervisors directed the Chief Administrative Officer to work with the Grossmont Healthcare District and Sharp Grossmont Hospital to initiate a pilot program in rural communities. County Fire, through the partnership with CAL FIRE, partnered with HHSA to operationalize the pilot program in the Mountain Empire. The pilot program was funded through $60,000 from the Grossmont Healthcare District, $114,000 from one-time Health Realignment, and $300,000 in General Purpose Revenue. The pilot project was intended to show the potential cost savings/avoidance to Sharp Grossmont Hospital and determine if those dollars could be applied to a permanent program to offset County costs.
Rural Health Post-Hospital Discharge Pilot Results
On June 26, 2023, the pilot program was officially launched. Working as a team, a County Public Health Nurse reinforced the hospital discharge medical direction, verified if a follow up appointment with a primary care physician had been scheduled, performed clinical and social assessments, provided case management services, and made referrals to the County’s self-sufficiency programs such as Medi-Cal and CalFresh, and the Aging and Independence Services programs, including In-Home Supportive Services. San Ysidro Health became a critical partner to receive primary care referrals at their Campo Clinic, as did Southern Indian Health Council, Inc. to coordinate care for tribal members. The paramedic evaluated the residence for defensible space clearing to reduce wildfire risk, identified any safety hazards inside the home (i.e. trip hazards and fire alarms), and in the event the patient was critically ill, initiated the 911 response for an ambulance transport to the hospital.
During the first seven months of the pilot program, the following results were observed:
• 168 patients were referred to the program upon discharge from Sharp Grossmont Hospital
• About 40% or 61 patients chose to receive post-discharge services
• The 30-day readmission rate for those who entered the program was 4.0%
• The 30-day readmission rate for those who declined the service was 13.9%
• Primary health insurance status includes: 23% Medicare-only, 21% Medicare-Medi-Cal, 29% Medi-Cal-only, and 27% commercial insurance (For 18 patients, no insurance status was provided)
• 234 home and 74 phone visits were made with the average patient having four contacts
• Enrolled patients who were readmitted had an average of 26 days from discharge compared to 17 days before readmission for those who declined services.
Some of the gaps identified early in the program were the extensive health and social service needs that impact quality of life and can lead to readmission. This included clients without fresh and healthy food due to lack of financial resources or the long travel distance to the closest grocery store. In addition, some individuals had residential issues such as inoperable plumbing leading to potentially unsanitary living situations. If the program continues, County Fire will seek to leverage existing programs to address social service needs. Authorizing County and CAL FIRE staff to be reimbursed for groceries, basic hardware supplies to fix appliances (including but not limited to toilet, sinks, and lights), and medical devices is critical to ensuring patients’ needs are holistically met, homes are safe to live, and hospital readmissions are reduced.
Sharp Grossmont Hospital has been a key partner during the startup and ongoing implementation of the pilot program and one of their commitments, through the Grossmont Healthcare District, has been to evaluate the cost savings/avoidance for reducing the 30-day readmission rates. With Medicare specifically, there are established penalties if patients are readmitted within 30 days for the same medical condition that previously resulted in hospitalization. According to Sharp Healthcare, during the first six months of the pilot program, annualized over a full year, the cost avoidance/savings from reduced unplanned readmissions is estimated to be $350,000. In addition, there remain costs that cannot be quantified. Since the start of the COVID-19 pandemic, emergency departments and hospitals have experienced patient volume increases that stretch physical and staffing resources. Each unplanned visit that is avoided promotes bed availability within the hospital and Skilled Nursing Facilities and reduces the long wait times at hospitals by ambulance transportation providers.
Behavioral Health Services
During the pilot, Behavioral Health Services (BHS) provided technical assistance to the implementation team regarding accessing behavioral health resources for clients while enrolled in the pilot and for post-discharge planning. Typical access points for behavioral health services include the general Access and Crisis Line, which provides brief screening and referrals to countywide resources, inclusive of BHS and other insurance providers, as well as accessing integrated behavioral health services through a referral to a primary care clinic or Federally Qualified Health Center. BHS also provided specific information about the BHS Rural Integrated Behavioral Health and Primary Care contract, which provides collaborative care services in the San Ysidro Health Campo clinic within the geographic region of the pilot. BHS will continue to collaborate with the implementation team regarding accessing behavioral health services.
Program Expansion
The pilot program data demonstrates that clients enrolled in the program were more likely to avoid a 30-day readmission than those who declined the services. In addition, Sharp Grossmont Hospital identified savings that directly benefit the healthcare system, and clients received enhanced care that supports their overall well-being. If the Board authorizes the Mountain Empire program to continue, County Fire will engage with other healthcare providers in rural communities to determine if there is a need and to determine what funding may be available. However, the staffing costs for County Fire and HHSA are not currently available and revenue agreements would need to be established to fully offset County expenses. Pilot program expenses will be about $460,000 for the HHSA Public Health Nurse (approximately $175,000), the CAL FIRE Fire Captain Paramedic (approximately $260,000), and other program costs (approximately $25,000).
Rural Health in Nursing Schools
HHSA, in partnership with County Fire, has explored partnering with local nursing schools to implement rural health learning experiences. Preliminary conversations with San Diego State University and California State University, San Marcos have been positive. County staff will continue engaging with the nursing schools to identify curriculum updates and internship opportunities in our rural communities. Providing educational and career opportunities in our rural communities will promote the health and well-being of rural residents and their unique needs.
Today’s recommendations include receiving a presentation regarding the Rural Health Post-Hospital Discharge program and communicating potential next steps for County staff to make the program permanent or end it after the pilot phase concludes on June 30, 2024.
LINKAGE TO THE COUNTY OF SAN DIEGO STRATEGIC PLAN
Today’s request supports the Equity Initiative of the County of San Diego 2024-2029 Strategic Plan by reducing healthcare disparities in our rural communities and supporting vulnerable residents in some of our region’s most underserved communities.
Respectfully submitted,
Sarah Aghassi
Interim Chief Administrative Officer
ATTACHMENT(S)
N/A