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SF Hospitals Grapple with Repeat Psychiatric Patients, Frustrated Workers
Sunday, August 07, 2022

SF Hospitals Grapple with Repeat Psychiatric Patients, Frustrated Workers

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.  

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“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.” 

David Sjostedt can be reached at [email protected].
  • The actions of “frequent flyers” amid the street dweller community have been known for years. So this is nothing new. And as “they” do not have health insurance, the cost of their shipping and handling comes out of the tax payers pockets.
    A quota should be placed upon those who do not have health insurance,limiting treatment to on site medical care only so that those who are seriously in need of care be prioritized (a form of triage).

  • As someone who has witnessed our very broken mental health system first hand I have never once seen a complete, thought-through recovery plan with adequate support for a patient after being hospitalized. Ever. Doctors often just park patients on medicine and assume that will fix it, when studies have shown such meds have dangerous side effects and negative long term impacts including higher rates of relapse. They can also cause severe mental breaks/symptoms if stopped too quickly. Coming up with an intensive after care plan – one that includes follow up, wellness coaching/therapy outside of drugs alone, and safe spaces for long term recovery – is something that’s been done (see the Soteria project in San Jose) but still hasn’t been implemented. Maybe the fact that the commentary and slant of this article still treat mental health patients as public nuisances unworthy of help is part of the reason.

  • So why don’t they have insurance? Are they not eligible for some form of ACA? Or Medical? Surely there could be advocates actually taking action and getting them enrolled while they are receiving services. This is a big problem with homeless population, who are made promises by city social workers but end up lost to followup, and I am told by many that it is city workers who do not complete the task. Just quoting them.

  • I listened to the meeting and what stood out for me, is the lack of communication between involved city organizations and the lack of followup with repeat offenders. Perhaps it is time to change how the the holds are handled for repeat offenders. If there are only 5 repeat offenders taking up so much time, assign each of them a permanent handler. How hard can it be for a professional social worker to keep track of 1 person to make sure they followup on the programs they are on?

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