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Audit highlights high cost of homeless ‘high users’ of emergency services

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A city audit found that 5 percent of emergency service users account for 52 percent of the total service cost. (Kevin N. Hume/S.F. Examiner)

More than half of the cost to provide emergency services to those suffering from mental illness and substance use is caused by just 5 percent of the total patients served, according to a new city audit that calls for increased access to supportive housing and services for those patients.

Of the 44,809 adults who accessed the City’s urgent and emergency services in fiscal year 2016-17, 5 percent, or 2,239 adults, accounted for 52 percent of service use. Of these frequent users, 90 percent have behavioral health diagnoses and many are homeless, according to the budget analyst’s audit requested by Supervisor Ahsha Safai.

The report said that the frequent users accounted for approximately $266 million, or 52 percent, of the total cost of $511 million in FY 2016-17 for urgent and emergency services.

Safai called the report “eye-opening,” saying that while it is common knowledge a small number of people, often referred as “frequent fliers” or “high users,” repeatedly end up in emergency care, what “jumped out” in the findings was the actual cost.

“How do we reduce that cost and get the level services for those 2,200 individuals?” Safai asked during Wednesday’s Board of Supervisors Government and Audit and Oversight Committee hearing. “Emergency care can’t be the answer.”

Kavoos Ghane Bassiri, director of the Department of Public Health’s Behavioral Health Services, said that “this is a serious concern for us as well. It is impacting our system when they are coming in.”

The audit estimated that “approximately 1,320 homeless adults who have behavioral health diagnoses and are high users of urgent and emergent services need access to supportive housing.”

Bassiri said “we are looking at each case” and have identified 500 of the high users impacting the system the most. “We are working at coming up with individual plans,” Bassiri said. “We need to really understand this group and understand what their needs are.”

Bassiri refuted one aspect of the audit that said 38 percent, or 1,786, of the patients were discharged from Zuckerberg San Francisco General Hospital’s Psychiatric Emergency Services without a referral plan to services.

“No one leaves psych emergency without a referral plan,” Bassiri said.

He said he had reviewed these cases and found that when patients were discharged and were already involved in service plans they were listed as “refer to self.”

But Bassiri did agree with the audit’s finding that The City needed to do more to ensure those discharged are following up on their service plans for treatment. “Referral to linkage is the area we need to work on more strongly,” he said. “We need to have the staffing to make that linkage.”

Safai said that the audit should serve as a foundation for the department and nonprofits to make a request for funding to better address the challenges. Mayor London Breed and the Board of Supervisors are currently debating how to use a $181 million windfall from property tax revenue from the state’s Educational Revenue Augmentation Fund.

Safai had also requested another audit on the needs of the jail population, which found that more than 70 percent of people booked into jail had a history of substance use or substance use and severe mental illness. Those with a history of substance abuse and mental illness have the longest stays in jail and the highest rearrest rates, the audit said.

Supervisor Rafael Mandelman has partnered with Mayor London Breed on pending legislation to expand the city’s power to place chronically homeless people suffering from mental illness and substance use into conservatorships, or court order treatment and supervision programs.

“San Franciscans expect us to deal with a very challenging population that we do not want to have in jail nor do we want to have in long-term hospitalization,” Mandelman said. “We, as a city, are not managing that anywhere close to adequately right now.”

He added, “I hope folks in the department will not hesitate and our nonprofits will not hesitate to let us know what you need from the city to get to a better place because we are not in a good one now.”

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