A relatively small number of patients are repeatedly cycling through the city’s psychiatric emergency facilities, driving up costs and tormenting hospital workers who say they need more staff to appropriately treat their clients.
A hearing led by Supervisor Rafael Mandelman on Thursday revealed gaps in psychiatric care amid an ongoing substance use and mental health crisis, with hospitals reporting repeat emergency patients who don’t seem to get connected with sustained care. More than 60% of patients who cycle through Zuckerberg San Francisco General Hospital’s psychiatric emergency unit leave with nothing more than a referral for outpatient treatment, according to a presentation by the Department of Public Health.
“Handing someone a piece of paper is likely an inadequate kind of referral,” Hillary Kunins, head of behavioral health at the Department of Public Health, acknowledged.
Five individuals have accounted for nearly 2,000 ambulance trips in the last 5 years, costing around $4 million in fees, according to April Sloan, community paramedicine chief for the San Francisco Fire Department. Mark Leary, deputy director of General Hospital’s Department of Psychiatry, confirmed that repeat patients are driving up the number of visits to the unit.
“There’s still a small number of patients who return very frequently to the [emergency department] and to the [psychiatric emergency services],” Leary said.
Mandelman, who has advocated for more compulsory care for the severely mentally ill, probed department representatives on the use of involuntary holds.
Discharge data from General Hospital’s inpatient psychiatry unit showed that more than 17% of patients left the hospital against medical advice. But Leary said that this number is largely made up of people suffering from substance abuse disorder, who don’t qualify for a conservatorship—which is reserved for people solely in mental health crises. While housing conservatorships do include people with substance use disorders, the option has only been used twice since its implementation in Sept. 2018, according to a report from February.
Mandelman, along with representatives from General Hospital and the police and fire departments, described a lack of collaboration between the Department of Public Health and other agencies that are responding to mental health crises, leading to repeat patients falling through the cracks and frontline workers feeling overwhelmed.
Supervisor Rafael Mandelman speaks at a press conference outside of City Hall on May 12, 2022. | Chris Victorio for The Standard.
Mario Molina, head of SFPD’s crisis intervention unit, said that police officers are dropping off patients but are rarely informed of outcomes, often seeing the same person on the street again. Molina suggested that departments begin sharing data on clients to help coordinate a response.
Karen Hill, director of staffing at the Department of Public Health, said that their analysis found only two vacancies within their psychiatric emergency service department. But medical professionals who phoned into the meeting described unsafe conditions in the emergency unit, which they attributed to a lack of staff to provide intensive care.
“It’s very concerning to me when we talk about staffing [psychiatric emergency services] and [DPH] reports that we don’t have a problem,” said Heather Bollman, a registered nurse at General Hospital. “These are [comments] that are coming from the boots on the ground.”
Kunins pointed to a newly launched office of coordinated care, which aims to increase rates of follow-up for people who enter the city’s mental health system by facilitating collaboration between departments. Kunins also expressed hope that a new sobering center in SoMa as well as a crisis diversion center scheduled to open in 2023 would alleviate the pressure on frontline emergency staff.
Mandelman said that he plans to call another hearing to further define the department’s plan to create a crisis diversion unit, which he warned could take on a different role than its original intent. He pointed to the Tenderloin Center as a project that “meandered” into becoming a safe consumption site after initially being intended to link people to treatment.
“I think we’ve done some good things,” Mandelman said. “And yet I continue to feel that we are not set up to address a challenge that we have seen now for many years.”
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