Healthier Outcomes through Multidisciplinary Engagement (HOME): A Multidisciplinary Case Management System for Chronic Users of the Emergency Department

Frequent users of San Mateo Medical Center's (SMMC, California) Emergency Department (ED) reflect vulnerable populations, including the homeless, substance users, low-income, and those with co-occurring disorders or multiple chronic conditions. Since SMMC is a public hospital, frequent users, those who use the ED 7 or more times in 12 months, are a significant drain on limited resources. The Healthier Outcomes through Multidisciplinary Engagement (HOME) team targets these frequent users with the goal of reducing visits, promoting use of primary care and improving health outcomes through comprehensive case management. Once clients are enrolled, a case management team, comprised of social workers, public health nurse and community worker assist clients by assessing their health and social needs and acting as a bridge for them to obtain the appropriate community resources. Preliminary findings show that since July 2007, 50 clients have been enrolled, of which 68% are male and 34% are homeless. Among first quarter clients (those enrolled July through September), 79 ED visits were recorded 3 months prior to enrollment. This was reduced to 36 visits 3 months after enrollment, and there was an increase in the number of primary care visits. The HOME team has been successful in lowering ED visits and demonstrating successful collaboration among various agencies across our community. This model, developed based on various programs that are in existence in other Counties across the state, is likely to be a cost-effective strategy to reach these clients and impact their utilization behavior, while improving their health outcomes.