New report shows gaps in mental health care for homeless

Nearly 40 percent of those released last year from San Francisco’s psychiatric emergency services were discharged without connections to other services, putting these mostly homeless people at greater risk for mental deterioration and a return to drug and alcohol use, according to a new city audit.

Of the 6,704 discharges from the psychiatric emergency unit at Zuckerberg San Francisco General Hospital last fiscal year, 4,666 involved a homeless person, according to the Budget and Legislative Analyst’s Office audit of the Department of Public Health’s Behavioral Health Services.

But 38 percent of the discharges — 1,786 discharges of those who were homeless and 776 discharges of those who were housed — didn’t result in the person being connected or referred to services.

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“Clients accessing psychiatric emergency services often have dual mental health and substance use disorders and experience homelessness,” the audit said. “Linking these clients to services on discharge is important, because without service linkage, these clients are at risk of not only decompensating mentally, but of also resorting to alcohol and substance abuse after being discharged.”

The number of discharges could include the same person multiple times. The audit found there were actually 3,229 unique persons discharged, less than half the total discharges. The auditors were not able to determine how many unique persons were homeless.

Jennifer Friedenbach, executive director of the Coalition on Homelessness, said The City was “returning people back to the streets at alarmingly high rates.” She added, “Returning them to the street is not good medical practice at all. They need to do whatever they can to find a place for them.”

The audit attributes the lack of connection to services to several factors, including “insufficient intensive case manager staffing to assist high-risk clients, clients choosing not to engage in further treatment, and a mismatch between the hours when clients access psychiatric emergency services (especially evenings, nights, and weekends), and when outpatient programs are open.”

Another finding in the audit was that of the 44,809 adults who used The City’s urgent and emergency services last fiscal year, five percent accounted for more than half of the total service use and most of them “have behavioral health diagnoses and many are homeless.”

“These 2,239 adults need access to medically-intensive supportive housing and intensive case management services, but as noted in this report, the demand for these services exceeds the supply,” the audit said

The 149-page audit makes 15 recommendations for improvements.

Barbara Garcia, director of the Department of Public Health, wrote in response to the audit that “Although DPH does not agree with all of the conclusions reached in the report, we do agree with the report’s recommendations in concept.” She added, “We are pleased to find that many of the issues highlighted in the report coincide with improvement efforts currently underway.”

The response said two staff members were assigned to improve referrals of discharged psychiatric patient and “reducing paperwork for referral and providing transportation needs to be considered.”

The department’s Health’s Behavioral Health Services, which includes nonprofit health clinics, treats more than 30,000 residents annually and costs about $370 million. Two-thirds of the cost for the services are reimbursed by federal and state funds, such as through Medi-Cal.

Other findings included that multiple health clinics are not providing the amount of services they are contracted to provide, leaving money unspent and needs unmet.

The department said that staffing is among “the most significant difficulties” facing nonprofits. “The cost-of-living in San Francisco is a particular challenge in hiring and retaining qualified staff for health/social service positions.”

Supervisor Ahsha Safai, who requested the audit, said he is still being briefed on its findings and plans to hold a hearing on it as early as next month. He said he wants to determine whether “we have the right level of and are we effective in providing mental health services in San Francisco.”

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