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Innovation

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 SanFrancisco General (ZSFG), 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.

ZSFG 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 ZSFG 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 ZSFG 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.