Caring Wisely FY 2023 Project Contest

Optimizing Purchased Services for Reducing Avoidable Days and Closing Social Needs Gaps

Proposal Status: 
  • PROJECT LEAD(S): Sarah Imershein, Molly Shane
  • ABSTRACT – The Department of Care Management and Patient Transitions oversees a large volume of purchased services coordinated by Social Workers and Case Managers.  These are non-billable services, that are not (currently) tracked in a structured way in APeX.  This is predominantly transportation and lodging, but may include medication assistance, post-acute care, or other services we cover to facilitate more timely discharge, e.g. negotiating post-acute care for $50,000 for a year is far less costly to the Health System than the > $1M it would cost to keep a patient admitted.  Most expenses are much smaller, in the $20-200 range, but this amounts to >$1.5M of purchased services/year, and continues to grow.  As of FY23, the Department oversees both Adult and Peds, East and West Bay, as well as many services coordinated through Ambulatory clinics.   Utilization has historically been tracked retrospectively via the invoice process, but is hampered by the long lag-time, and lack of utilization detail in line item variance reports (e.g. “Other Services” is one line item). We propose optimizing the invoicing process and link to the patient-level upstream utilization, so that costs can be tracked more prudently, appropriate patients are connected with appropriate resources (e.g. social determinants of health are addressed), and purchased services that facilitate speedier discharge are leveraged to the fullest.
  • TEAM – Sarah Imershein, Patient Transitions Operations Manager; Molly Shane, Executive Director Care Management and Patient Transitions; Trevor Haines, Assistant Director Peds Case Management;, Don Rowland, Assistant Director Adult Case Management; Meher Singh, Assistant Director Adult Social Work; Emily Price, Social Services Operations Manager Oakland; Shabren Harvey-Smith, Director Social Services Oakland; Rosa Solorzano, Assistant Director Peds Social Work; Sharly Lembkey, Executive Assistant.
    • Long LOS/avoidable bed days
    • Unmet gaps in social needs
    • Over-/under-utilization of purchased services
    • Deteriorating vendor relationships
  • There is currently no mechanism to connect patient level utilization to the monthly variance reports used for tracking cost.
  • Utilization of purchased services has been increasing with only anecdotal understanding of the drivers, including which departments, hospital services, or units are highest utilizers; what patient types tend to use services; and whether patients with identified social needs are getting appropriately connected to these services.   There is hypothesized to be a large unmet need of eligible patients currently NOT receiving services, that if did, would facilitate shorter LOS, decrease avoidable days, improved throughput, and higher volumes. 
  • TARGET -  The goals of this project:
    • Decrease avoidable bed days by 10% from 2511 avoidable days annually to 2260 avoidable days by coordinating appropriate purchased services.  This would generate $958,198 of incremental margin
    • Analyze utilization patterns of purchased services to identify areas of over-/under-utilization
    • Increase the % of patients with identified gaps in social determinants of health with appropriate services
  • GAPS – 
    • Technology
      • Significant technology barrier in that whatever system is devised (off-the-shelf or custom built), it must be able to handle P4-level PHI.  Invoices often contain the records of the services provided, including Patient Name, MRN, etc (e.g. list of all ambulance rides in an invoice, or LOAs that must be included to confirm authorization of payment).  Currently, products like Smartsheets cannot be used as a solution since there is no BAA between Smartsheets and UCSF. 
      • Currently, UCSF uses a paper-based system to obtain authorizations for large ticket items that needs to be made electronic. 
      • Structured data collection at the patient level – currently there is minimal structured collection of data on purchased services at the patient-level – APeX has had FLO rows added recently, but incomplete across all disciplines and types of services that must be tracked – no roll up into an integrated system to track utilization
    • Trend analysis –
      • Currently utilization is monitored only retrospectively once vendor invoices are received, often months, if not years later, making timely course correction not possible. 
      • Currently, there is no close-the-loop function between AP and the Department to notify when vendors are actually paid, resulting in wasteful re-submitting of invoices, and deterioration of vendor relationships.
    • SDOH Screening (Social Work)
      • New SDOH screening has been implemented partially in Social Work, and is impending health system wide with new CMS rules this coming year (FY24)
      • Inconsistent linkage to services when SDOH gaps identified
    • Discharge Planning Screening (Case Management)
      • Case Management currently follows ~ 40% of adult inpatients and >90% of pediatric inpatients – potential to miss non-CM patients that if provided minimal additional services (e.g. transportation), may discharge faster
    • Intervention
      • Invoice Tracking System – modification of existing (Excel-based), or new solution for tracking individual invoices and categories of utilization (details not included in monthly variance reports); linkage to patient-related information (authorizations, LOAs, etc.); close-the-loop communication with AP to decrease payment cycle time
      • Gather Upstream Patient-level utilization data - APeX FLOs developed to capture when purchased services are administered to patients – some existing already; some need development – including in-basket or other communication mechanism for authorizations
      • Cost Analytics – Utilization trends analyzed so areas of under/over-utilization addressed to facilitate speedier discharges; joining of SDOH screening to purchased service interventions as evidence of addressing unmet social needs
    • Setting – Hospital Encounters and some Ambulatory encounters, Adult and Peds, East/West Bay
    • Barriers
      • Tiny expenses - historically tiny expenses (e.g. “a muni token”) have not been tracked robustly and changing behavior to document thoroughly may be challenging;
      • SDOH universal screening is not yet implemented – limited set of identified high risk patients, or those identified through social work assessments – will not have complete picture of need until universal screening and workflows established
      • Accounts Payable – AP does not have communication channels established back to departments when invoices are processed – need coordination to meet their needs
      • Organizational Change – Tracking all these expenses is new - change in how resources are allocated
    • Adverse outcomes – no known adverse outcomes
  • PROPOSED EHR MODIFICATIONS Note: EHR modifications are NOT required for a winning proposal
    • Problem to be solved - tracking patient-level utilization of purchased services
    • Tools -  Flowsheets currently implemented for Social Work, but has not been robustly rolled out or given audit feedback – need to expand to Case Management, as well as ensuring all Adult and Peds stakeholders have access; in-basket or other communication tool needed for alerting managers to high ticket items (transition out of email); SQL report or other reporting needed to feed into utilization database – May be other APeX “solutions” other than Flowsheets that could accomplish this goal
  • COST – In CY2022, Case Management documented 2511 Avoidable Days related to Community Delays, Patient/Family Delays, and Payer Delays.  Many of these delays have potential to be mitigated by using purchased services to facilitate discharge.  If eliminated, this represents $9.6M in incremental bed day margin (Average daily contribution margin for all UCSF inpatient visits in CY22 is $3,816).  We propose to reduce these avoidable days by 10% from 2511 to 2260 avoidable days, for $958,198 generated incremental margin.

Community Delays


Acute Rehab Bed Unavailable [62]


Bariatric Needs [70]


DME Provider - Delayed or Not Available [67]


Hospice Services Unavailable [66]


Long Term Care Bed Needed, Not Available [60]


LTACH Bed Unavailable [63]


Outpatient Dialysis Chair Not Available [69]


Outpatient Service are Unavailable [71]


Outside Hospital Bed Unavailable for Hospital to Hospital Transfer [61]


Pending Foster Care Placement [72]


Psychiatric Bed Needed, Not Available [64]


SNF Bed Needed, Not Available [59]


Patient/Family Delays


Family Refused to Care for Patient [77]


Family/Patient Representative Not Available [76]


Guardianship/Conservator Pending [80]


Patient has History of IV Drug Abuse [79]


Patient Refuses to Leave [74]


Patient/Family Refuses to Participate in Discharge Plan [73]


Planned Transportation Failed [75]


Payer Delays


Payer Delay in Authorization [98]


Payer Does Not Cover Patient Discharge Needs [99]



Total Avoidable Days



  • SUSTAINABILITY – This project is to establish the infrastructure mechanism for tracking this activity that would be sustained indefinitely within the Department.  The staffing and desire to perform this function already exists, just lacking the technical tools, APeX enhancements, and implementation support to make it a reality.
  • BUDGET – 
    • Project Management salary support $20,000
    • Smartsheets or other applicable software implementation $8,000
    • Dashboard development, contracted vendor $22,000