Originally published in SF Chronicle.
By Drew Joseph
March 24, 2013
Hervy Luster’s blood pressure flashed 133/86. The top figure had been above 150 a few weeks prior.
“That’s awesome,” said Dr. Dave Moskowitz.
“The garlic is working,” Luster, 59, said with a laugh, explaining he had eaten lots of garlic lately.
“Not saying the garlic isn’t working,” Moskowitz said, before suggesting that it was probably Luster’s improved adherence to his drug regimen.
Luster, who has congestive heart failure, is a patient at the Hope Center, an initiative from the Alameda County Medical Center to help people who struggle to manage their chronic conditions. The patients generally face other problems – including substance abuse, poverty or a lack of stable housing – that compound the challenges their illnesses present.
The Hope Center is part of a larger statewide effort to bolster care at public hospitals. Its specific goal is to reduce the number of hospitalizations of these “super-utilizers” who rack up major health costs. To be eligible, a patient has to have been hospitalized at least three times in the past year.
Looking after patients
The center’s staff includes Moskowitz, who is the medical director, and a social worker and nurse care managers. They help oversee prescriptions, coordinate appointments and make sure patients get to them, and visit the patients to get a sense of what they are facing outside the doctor’s office.
“They help me professionally and personally,” Luster said.
Luster was hospitalized seven times in the past year. He used to drive a taxi, but does not have stable work right now. He is renting a room in Berkeley, but a social worker from the center is helping him try to land a spot in an assisted living facility.
A special federal-local partnership made the Hope Center possible. In 2010, the federal government approved a waiver called California’s Bridge to Reform to help the state prepare for the Affordable Care Act, the major components of which kick in next year.
Matching federal funds
The component of the waiver that helped pay for the Hope Center was the Delivery System Reform Incentive Pool, which offered more than $3 billion in federal matching funds to public hospitals to help boost care. Twelve California county hospital systems and five UC hospital systems have pursued the funding for a variety of improvement projects.
“It’s about preparing the delivery system for a different era in which more people have insurance, and with that insurance, more choices in where they get their care,” said Chris Perrone, the deputy director of health reform and public programs at the California HealthCare Foundation.
Millions of Californians are set to gain insurance as the Affordable Care Act goes into effect, either through marketplaces known as exchanges or the expansion of the state’s Medicaid program, Medi-Cal.
For safety-net providers, there is some concern that once people have insurance, they may choose to head to private hospitals and clinics for care, leaving a hole in public facilities’ coffers. One reason to provide the funding to public hospitals was to make them more competitive.
Millions still uninsured
“We want to earn their business,” said Erica Murray, the senior vice president of the California Association of Public Hospitals and Health Systems. “We know folks will be able to choose, and we think there are a lot of assets that public hospitals can leverage.”
Three million to 4 million people in California will lack insurance even with the Affordable Care Act, according to a UC Berkeley and UCLA report. And Murray said those people will continue to depend on public hospitals.
To get DSRIP funding, hospitals had to meet performance benchmarks. The efforts ranged from improving service to at-risk populations to reducing hospital-acquired health problems.
Benchmarks for funds
San Francisco General Hospital, for example, is working on ways to manage sepsis and prevent central-line-associated infections and deep vein thrombosis.
In addition to DSRIP, the waiver included funding for the Low-Income Health Program, which extended health coverage to adults near poverty. Overall, the waiver opened up more than $8 billion in federal funding over five years that had to be matched by California counties. The federal spending had to be budget-neutral and use savings from changes in Medicaid coverage.
At the Hope Center, the goal is to help patients get to where they can manage their conditions without trips to the hospital, and then transition them to traditional primary care. It could lead to better health outcomes and savings, although Moskowitz acknowledged that not all patients will be able to make such progress.
The center, which opened in January, has 24 patients with a capacity of up to 200 as more staff is hired. It operates out of the Eastmont Wellness Center, with plans to move to a permanent space at Highland Hospital this spring.
“These patients are very sick and very marginalized and don’t have a lot of resources,” Moskowitz said. “The business case aside, my take on this from an ethical or moral standpoint, it’s incumbent on us to direct the most resources to the patients who are experiencing the most suffering. And that’s really the folks we’re taking care of.”
Edited on June 11, 2018.