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San Francisco Fire Department could soon place emergency psychiatric holds

A proposal to give fire department paramedics the authority to place 5150 holds, or involuntary psychiatric holds for individuals in severe mental distress, will advance to a vote in the coming weeks. 

The Board of Supervisors’ Public Safety and Neighborhood Services Committee voted unanimously on Thursday to advance the proposal, which would designate fire paramedics to initiate the holds, to the full board. Currently, only SFPD officers and licensed clinicians have the ability to initiate 5150 holds.

“Our paramedics are licensed healthcare providers…we have the trust of the public, and we work 24/7 on weekends and holidays,” said Chief Simon Peng, who leads the department’s community paramedicine program, at a hearing on Thursday. 

According to an annual report by the San Francisco Department of Public Health (DPH), there were 8,975 total 5150 holds placed in San Francisco in the fiscal year of 2020, or between July 2019 and July 2020. Of those, 2,224 occurred at Zuckerberg San Francisco General Hospital’s emergency psychiatric unit, while the remainder occurred at local hospital networks. Individuals detained at General Hospital averaged 2.8 visits per year, and 450 individuals were detained at least twice over the course of the year. 113 were detained four or more times.

Police officers were involved in about one-third of all 5150 holds, with 3,043 SFPD incidents resulting in a hold over the course of the year. In half of those calls, the caller was a stranger reporting an individual in distress, and in 61% of cases the individual was determined to be a danger to themself. The individual was deemed a danger to others in 38% of cases.

“Having been on the ambulance myself for many years…I saw the revolving door,” said San Francisco Fire Department (SFFD) Chief Jeanine Nicholson on Thursday. “You’d take someone to the hospital, you’d be sitting there writing your paperwork and see them walk out. Then you’d pick them up again a few hours later.” 

Fire department officials argued that paramedics, who have access to health records and are medically trained, would be more effective in initiating 5150 holds than police. They speculated that if placed under the fire department’s purview, the total number of 5150 holds may even decline over time by diverting frequent flyers to longer-term care. 

Minimizing police involvement in such calls could also help remove the stigma associated with mental health crises, added Adrienne Sims, director of Local 798, the labor union that represents San Francisco firefighters. 

“Mental health issues are stigmatized in our communities,” Sims said. “Having the police on scene can escalate a situation that can, oftentimes, be handled by our teams.” 

City officials have sought to divert other street-level calls, such as those involving drug overdoses, to agencies other than the police as part of a broader reform initiative.

In the upcoming budget, San Francisco plans to fund additional community paramedics along with a slew of other teams tasked with addressing various street-level crises and concerns. By January 2022, SFFD plans to have a total of 22 community paramedic teams in operation, along with its EMS-6 paramedic units. 

The fire department also manages six Street Crisis Response Teams, which respond to behavioral health calls, with a seventh planned in the coming months. Mayor London Breed has also proposed new Street Overdose Response Teams, which SFFD and DPH would jointly run, and a Street Wellness Response Team run by SFFD and the Department of Homelessness and Supportive Housing. 

Specifically in the Tenderloin and downtown areas, San Francisco is also funding a number of so-called “community ambassadors,” including many nonprofit workers, to act as a helpful presence and resolve quality-of-life concerns in lieu of police officers. 

“It’s part of a larger movement of shifting response to people with mental illness away from police,” said District 11 Supervisor Ahsha Safai, who co-authored the proposal to designate fire paramedics for 5150 holds. “It’s a public health function.”