"There is no greater issue in the City and County of San Francisco" than homelessness, Mayor Gavin Newsom declared recently.
Most experts agree that breaking the cycle of homelessness means addressing the mental health needs of that population. In San Francisco, an estimated 50 percent of the homeless have some kind of serious psychiatric diagnosis, often leading to crisis situations involving the police.
San Francisco General Hospital (SFGH) is the only hospital that receives what are called "psychiatric holds" from the police. Last year, more than 80 percent of Psychiatric Emergency Services (PES) patients were homeless. That means SFGH doctors, nurses and other support staff are also on the front lines of the mayor's efforts to dramatically reduce homelessness. "We provide the safety net for the most severely mentally ill people in the city," says Robert Okin, chief of psychiatry at SFGH.
And while psychiatric emergency services at other hospitals in the city have dwindled over the years, SFGH's psychiatric department has doubled in size in the past decade and the kinds of programs it provides have quadrupled. "The 100 beds we have available for inpatient psychiatric care have become an increasingly important resource for the city," says Okin, who is also professor and vice chair of the Department of Psychiatry in the UCSF School of Medicine.
More than 40 percent of the 7,000 people who are admitted for emergency services also require admission to the hospital for inpatient care. The average length of stay for those patients is 10 days.
Treating psychiatric patients - most of whom do not seek treatment voluntarily - is especially challenging, Okin says. "We have to become specialists in engagement." That means getting people to accept treatment and the responsibility of continuing that treatment after leaving the hospital. The most effective way of engaging homeless people, he says, is to find each of them a home and get them the social support they need to stay off the streets.
To that end, Okin developed the PES's Crisis Resolution Team about a decade ago. The team, made up of medical and psychiatric personnel, is designed to handle patients that are discharged from PES. The team helps patients find housing, links them with social services programs and helps those who want it seek treatment for substance abuse.
Mitzi Goya, the social worker who directs the program, says it is the only one in San Francisco that is based at a hospital. To be successful, she explains, her team members must establish relationships with patients while they are still in the hospital and, at least in the beginning, follow up with them on a daily basis. "If they didn't connect with us, they would be discharged from an inpatient unit to the streets with nothing but a bottle of medicine," Goya says.
Another key to success, Goya says, is getting patients to identify their own goals and help them reach those goals. "Their goal might be to get new dentures. Ours might be to get them back on their meds," she says. Establishing a trusting relationship requires that the team address such needs, while also trying to get the patient to comply with medical and psychiatric treatment. Housing, she says, is the most pressing need among PES patients.
Okin says that the team plays an almost parental role in its efforts to help patients permanently resolve their crisis situations and manage their mental illnesses. "This service is increasingly important," he points out. "We can't hospitalize everyone. There aren't enough beds."
Source: Camille Mojica Rey
Photo by Elisabeth Fall
