Critics charge that cost-cutting dismissal of social workers has led to poorer outcomes for patients and doctors — and costs more money
The patient at San Francisco General Hospital just wanted to die in peace. She had end-stage chronic obstructive pulmonary disease, but her daughter, who was also her caregiver, would often leave her at home for days. Alone, in her 90s, the woman would remove her oxygen tube and then call 911 when she lost her breath. When this became a frequent occurrence, a report was filed with Adult Protective Services and she was admitted to SFGH. With the help of doctors, she requested to be transferred to an inpatient hospice center.
And yet, after about 10 days, the patient was still languishing amid the noise and bustle of a medical unit meant for acute-care patients. The woman’s delirium worsened. The transfer should have been taken care of within one or two days, but her social worker was overworked on an unstaffed team, and needed more time — and the help of a doctor — to coordinate it.
For Dr. Leslie Suen, a third-year resident, this patient’s story is one more example of the mounting toll of a recent reduction of social workers. It has not only left patients like this woman in confusion and discomfort, but has also stretched the capacity of the staff — and may have added to a bottlenecking of patients that has cost the city millions of dollars.
‘’A lot of the time, social workers were so overwhelmed and residents had to take on some of their work. The plans that we create for patients have suffered,” Suen said.
In May — at a time when the demands on SFGH have never been higher — the hospital abruptly laid off seven to nine social workers for the Medical Surgical unit, an abrupt reduction of around 33 percent of those positions.
“It came out of nowhere,” recalled Dr. Scott Goldberg, another resident physician. “There was no announcement.”
The temporary social workers were given a cursory 10-day notice. They had been contracted through an independent staffing agency beginning in February 2017. But the registry fund through which they and other temporary workers were being paid was depleted, and all contracted employees were let go, according to Dr. Todd May, the Chief Medical Officer of SFGH.
Now, around 21 remaining permanent social workers have been responsible for the entire inpatient medicine unit. As a result, social workers have gone from handling 10 to 19 patients a day to sometimes seeing more than 40, according to numerous social workers and doctors. With fewer social workers, doctors like Suen and Goldberg believe the pace of discharges has slowed.
In a statement to Mission Local, the hospital says it is “standard practice for us to hire temporary contract-based workers and renew their contracts, or not, to adjust to budget constraints or other issues. This is what happened with the seven social workers in May/June of this year, not layoffs.”
While this quote from the hospital’s PR staff put the number of departed social workers at seven, Dr. May put the number at eight — and residents and social workers placed the total at nine.
Regardless, the hospital says that there is no correlation between the loss of social workers and the delay in discharges from the hospital. But May notes that more social workers were hired in 2017 to help improve upon just these sorts of delays and inefficiencies.
“This has been, basically, our No. 1 priority for some time now,” he said.
But he stressed that, as contractors, the social workers were never occupying permanent positions. And when the registry fund they were paid out of was gone, they were dismissed.
“That money ran out,” May said. “It wasn’t so much a cut. We were augmenting the resource and then were no longer able to do that.”
It is unclear why that fund was exhausted or at what point hospital management realized its funds would run out. About two months passed following the layoffs before the hospital formally acknowledged the loss of social workers to the doctors and remaining staff .
“We know that residents and faculty are concerned about the impact that staffing decreases have on patients, hospital work flow, and physician responsibilities,” Lisa Winston, who directs Inpatient Medical Services at SFGH, wrote in a July 9 email, in which she also attributed the “marked decrease” in social workers to “budget constraints.”
Last month, in response to employee complaints, hospital administrators told social workers and staff that they would hire five more permanent social workers. But that process takes months, and the replacements have still not been hired. It’s unclear why the permanent hires were not made from the temporary pool, or why they were not completed before the layoffs.
Stark repercussions: “a crisis every day”
The consequences have been stark, interns and social workers told Mission Local.
Temporary social workers say when they were first hired in 2017, the team was in desperate need for help. “You would come in and it would be a crisis every day,” one former temporary social worker said.
The Feb. 2017 addition of the contract workers was a breath of fresh air, said one permanent social worker, who asked not to be named. “You had time to work with families and come up with the best plan for them,” the social worker said.
But now, social workers have returned to conditions similar to the ones they faced before the extra help was added. Patients such as the dying woman, who had been signed off for hospice care, can easily get stuck.
“We are the dumping ground for everything the doctors and nurses don’t do or don’t have time to do,” the social worker said, stressing that the entire department is working long hours to try to keep up.
Unprecedented overcrowding: “another dimension”
Nearly every day for the last two years, San Francisco General Hospital — the region’s only trauma center — has been operating past capacity. As a safety-net hospital, SFGH serves the city’s poorest residents. The reasons for the hospital’s overcrowding are complex, including explosive growth in the volume of patients coming to the hospital’s emergency department, a remarkable trend administrators are still grappling to explain.
But the problem isn’t just augmented intake — numerous sources within SFGH agreed that the biggest barrier to moving patients smoothly through the hospital system is an inability to discharge them from the Medical Surgical unit when they no longer have acute needs.
This is one of the social workers’ primary responsibilities.
“The main crunch for us is our Medical Surgical units,” confirmed May, the chief medical officer, who’s been focusing on the hospital’s chronic overcapacity for the last 18 months. SFGH’s occupancy has been more than 100 percent nearly every month since August 2016, with a high of 110 percent capacity in February. Numbers began declining last summer, dropping to 99 percent in September. Since then, however, it has been growing again, reaching 110 percent in February 2018.
The hospital’s target is to operate at 85 percent capacity. This goal has not been met for years.
Patients across the hospital system — from the emergency room, critical care, surgery or clinics — converge on the Medical Surgical unit, which recently had to open up 15 more beds to address the overwhelming need. The unit now has 179 beds.
But, like the patient who wanted to transfer to hospice, a significant portion of these patients no longer need to be here.
After patients have been treated for their acute needs, these patients are re-categorized as needing “lower levels of care,” which means their stay at the hospital is no longer covered by MediCal or other insurance providers. It costs the hospital $2,800 a day — out of its own funds — to keep a lower-level patient. So, for the woman who stayed around for 10 days while waiting for a hospice bed, the hospital may have had to pay up to $28,000. That’s on top of losing outside revenue from a covered patient — a patient who actually needed the higher level of care.
Suen believes that had the social worker team been better staffed, it could have saved the hospital scores of thousands of dollars of lower-level of care costs on this one case — and untold numbers of dollars from many other patients.
According to statistics from Department of Public Health, there were 2,206 lower-level-of-care patients at SFGH between July 2017 and June 2018. Most of these patients remained at the hospital for three or fewer days, but 102 remained in the hospital for more than 30 days. In the previous year, 1,867 lower-level patients were treated at the hospital.
Hospital administrators told Mission Local they do not calculate the costs associated with these patients, but the city published calculations of lost revenue from lower-level-of-care patients between 2001 and 2002. At that time, it cost the city $3.9 million, a figure that has likely increased significantly over the last 16 years.
Lower-level-of-care patients are usually the most vulnerable patients, and frequently homeless. The city has tried to move such patients through the system smoothly — but, by removing social workers in May, the hospital constricted the exitway for them. And, while they did so due to budget constraints, it may have contributed to a costly source of revenue loss.
Social workers are responsible for coordinating the safe discharge of all patients. Some patients simply go home, but a social worker can spend a considerable amount of time trying to find a bed for a patient who needs follow-up care. A homeless patient in need of continued care, for example, cannot be discharged to the street, and an elderly patient in need of follow-up treatment may need an intermediary care facility.
Without a social worker making these determinations and getting the patient placed, they are not discharged and remain at San Francisco General. And, in a cascading effect, other patients who need more acute care end up stuck in inappropriate locations.
“They wind up staying in the emergency department, the ICU, the recovery room,” May says.
“This has been a problem for years, but it really crossed into another dimension about 18 months ago,” May continued, attributing the problem to an increase in emergency room admissions and corresponding reduction in services around the city.
Sharp increase in emergency room admissions and decline of discharge beds
SFGH’s emergency department has seen a 20 percent uptick in service every year for the last three years, according to May.
At the same time, the city has struggled to add discharge beds to its stock to keep up with the precipitous decline in beds in private facilities. The city’s board-and-care facilities, which provide residential treatment, have halved over the last five years, dropping from 70 to 38 facilities — providing beds to just 355 people, according to Department of Public Health figures.
Skilled nursing facilities have also taken a hit. According to the state Department of Public Health, the city has lost five skilled nursing facilities since 2010, a total loss of about 500 beds. Since 2003, there has been a 30 percent decline in skilled nursing facility beds in San Francisco, according to the city.
But as San Francisco’s population ages, May says, there is increased demand.
To make up for some of these losses, the city added discharge beds throughout the city, including 75 beds at Medical Respite, which offers discharge needs specifically for homeless patients, and 15 beds at Hummingbird Place, also designated for homeless people.
May also says the hospital has developed a kind of “SWAT team” that intercepts patients in the emergency department so as to “avoid unnecessary admissions” into the Medical Surgical unit.
Meanwhile, back at SFGH, the social workers and resident physicians have spent their summer working with a chaotic caseload that represents some of the most demanding cases in the city.
Suen, an active member in the resident’s union, conducted a survey of her colleagues to find out how their work has been affected. She found that residents had started doing social work on top of their 80-hour weeks.
“There was a lot work that wasn’t getting done because the social workers were so overworked: patients were staying in the hospital and things were getting dropped,” she said. Suen also said that some doctors reported ordering the wrong things for their patients.
Suen is now working to document specific instances of patient harm since the social workers were laid off.
She wrote a petition on change.org addressed to Susan Ehrlich, the hospital’s CEO, and to Glen Mcclintock, its director of social services, asking for the reinstatement of the social workers. She circulated it among her fellow physicians, gathering 174 signatures.
“I think the hospital has many issues, but it is the safety net for people who have nowhere else to go in what is a profoundly unequal city,” said Scott Goldberg. “So I have sympathy for the hospital and that they are trying to do the best they can. It’s unclear to us who made this decision to cut social workers.”