Life on the streets takes an enormous toll on the health of our entire community, particularly for our most vulnerable residents who live on the streets of San Francisco every day. This toll also has a profound impact on Zuckerberg San Francisco General, in particular, the Emergency Department where the percentage of patients experiencing complex social and medical needs has risen significantly in recent years because they have no place else to go for the variety of complex needs they face, let alone their medical needs.

Zuckerberg San Francisco General understands at its core that medical treatment alone does not entirely address many of the needs often encountered by patients that are triggered by complex social determinants to health, such as lack of stable housing, hunger, social isolation, substance misuse, depression and mental illness.

To address this increasing need, a multidisciplinary team of Zuckerberg San Francisco General social workers, pharmacists, nurses, physicians, performance improvement specialists and the Department of Public Health’s Transitions team have come together to provide patients and providers with safe alternative options that prevent hospitalization by assessing and treating these complex social determinants. This unique, multi-disciplinary program is called: Social Medicine.

Using the ED as a portal to the community, this innovative approach integrates effective patient communication and care coordination with tailored interventions to provide not only the best medical care for patients, but life-changing and transformative outcomes where patients can access the services in the community that truly match their unique and often complex needs.

With the increasing reliance these patients have on Zuckerberg San Francisco General and the services of the Emergency Department, the challenge of ensuring effective holistic or “whole person” care can now be addressed through this Social Medicine model of care.

Dr. Jack Chase addresses his team at a weekly meeting discussing the best strategies to help improve processes and outcomes. At top: Dr. Hemal Kanzaria addresses the Social Medicine team in the Emergency Department.


Jenna Bilinski, RN, Director of the Kaizen Promotion Office, coaches and teaches to align the team’s goals with the True North goals of the hospital.

Photos by Kevin Meynell