SF Planning Commissioners Tour SFGH Psych Units with POC
Commission President Calls for CPMC Psych Services
Psychiatrists Bob Buckley, M.D., Gil Villela, M.D. and John Rouse, M.D., all Physicians Organizing Committee (POC) members, led four San Francisco Planning Commissioners on tours of San Francisco General Hospital’s already strained mental health facilities in July and September to see first-hand the impact of a pending vote on California Pacific Medical Center’s (CPMC) Long-Range Development Plan. CPMC’s plan calls for building two new hospitals in San Francisco, with zero in-patient psychiatric beds.
The tours were the result of POC members testifying in front of multiple Planning Commission hearings pointing out the deficiencies in CPMC’s Long Range Development Plan (LRDP) with respect to mental health services. When Dr. Rouse, who has served as a psychiatrist in the Psychiatric Emergency Services (PES) unit at SF General Hospital for over 30 years, spoke at both the June 9 and September 22 hearings, he underscored the importance of the commissioners knowing first hand before the pending vote the level of the city’s most critical mental health services for the poor and invited them to the unit. Several of the seven commissioners expressed interest in accepting his offer.
Planning Commission President Olague, who came on the July 8th tour said, “I want to thank POC for offering me a first-hand, inside view of the critical issues facing San Francisco’s mental health services. I never would have had this opportunity otherwise.” Commissioner Hisashi Sugaya also expressed his appreciation for the July 8th tour by Buckley and Vilella, who is PES’s Jail Psychiatric Ward director. Sugaya said he would encourage Board of Supervisors member David Chiu to get the tour, as the Board will also have to approve the LRDP.
Dr. Buckley, a psychiatrist at PES for over 25 years, described the erosion of mental health services in the last decade and explained areas needing funding to improve patient care and staff safety, including additional acute inpatient and subacute beds, together with preventive outpatient services. He has been advocating for these needs since joining POC in 2005, shortly after CPMC shut down the 32-bed inpatient psychiatric unit (IPU) at St. Luke’s Hospital.
POC Operations Manager Brian Tseng noted that “The lack of mental health services is particularly burdensome on poor and working families.
The private hospitals don’t want to treat uninsured psychiatric patients, shifting the economic burden totally to the public sector, while enjoying government grants, tax breaks and other preferential treatment. The private hospitals focus on those with money and insurance to pay. The numbers speak louder than words with regards to the private hospitals neglecting their charitable care obligations.”
In 2006, an ad hoc grouping of local ER doctors, psychiatrists, EMTs, psychiatric social workers, hospital and city administrators did a six-week ‘5150 Impact Survey’ and found that uninsured patients have an average length of stay of 20.8 hours in emergency rooms, whereas insured patients only had an average length of stay of 4.6 hours before being transferred to psychiatric facilities.
According to Buckley, the St. Luke’s had served as a vital overflow valve for both PES and the locking acute inpatient wards at SFGH. “The acute psychiatric wards at SFGH were routinely full of patients — primarily transferred out of PES,” noted Buckley. “When the SFGH psych wards filled up, we could transfer patients from PES to St. Luke’s. After the closure of St. Luke’s IPU, PES ended up on “red alert” — full to capacity and unable to accept new patients a large part of the time.”
With no space to place patients, PES became increasingly backed up and ambulances would have to take acute psychiatric cases to medical ERs not specialized in handling them. Initially this occurred about 20% of the time. Since the city has drastically cut their own inpatient acute beds from 87 to 22, PES is on diversion around 35% of the time, according to Dr. Rouse.
When Commissioners Kathrin Moore and Gwyneth Borden toured the psych facilities on September 27, both commissioners saw patients who had been locked down for 39-70 hours, although PES is only supposed to keep patients for a maximum of 23 hours for observation, stabilization and release or transfer to an appropriate facility. After witnessing acute patients kept three to a one-person room in PES, Rouse pointed out a stack of emergency case files for 5-6 patients awaiting transfer from Kaiser and other hospitals, even though PES was already beyond capacity. According to Rouse, “those files represent patients who may be strapped down to gurneys for up to four days in medical ERs in other hospitals”
Rouse noted that, although PES is only licensed for 19 beds, there were 30 patients crammed into the unit a few days before the tour, setting a record for overcrowding. When Rouse, along with Dr. Valerie Gruber and other POC members raised these issues to the Planning Commission at the 22 September hearing, he began by holding up the 20 September issue of the SF Chronicle, featuring an article, “Stalemate on St. Luke’s Fate.” Quoting the article’s opening sentences describing St. Luke’s, “A sick child without insurance may share an ER room with a smelly, mentally ill patient strapped to his bed who screams, spits and swears,” Rouse continued, “That mentally ill patient should have been stabilized, fed, cleaned and treated in a mental health unit. But that didn’t happen because Sutter (CPMC’s parent corporation) shut down the 32-bed Inpatient Psychiatric Unit in 2005.”
He described the overcrowded conditions in the PES, the need to hold CPMC to their charitable obligations, and for CPMC to provide their share of psychiatric care, pointing out that CPMC has not planned a single psych bed in either their proposed 555-bed Cathedral Hill hospital project or their proposed 80-bed St. Luke’s Hospital. “The sum total of psychiatric resources for their entire four-hospital system in San Francisco will be the handful of existing beds at CPMC’s Pacific Campus, which have never served the chronically and severely mentally ill.” Rouse ended by asking, “Will there be psych patients strapped down to gurneys in the hallway for four days in the Cathedral Hill site’s gleaming new emergency room?”
Commissioners Moore and Borden agreed with Dr. Rouse and Mark Leary, M.D. deputy chief of SFGH’s psychiatry department, who briefly joined the tour, that more mental health facilities are needed. According to Rouse, in terms of psychiatric facilities, “CPMC is using a policy of, ‘If you don’t build it, they won’t come.’ Nevertheless many psychotic or suicidal patients make their way to the Medical Emergency Room at the St. Luke’s campus of CPMC. With no local mental health facilities, St. Luke’s has no way to give them adequate care. In many cases, overcrowding at SFGH makes transfer there impossible, and many patients wind up too quickly back on Market Street.”
Commissioner Borden indicated she would contact Supervisor John Avalos, who has frequently spoken at Board of Supervisors meetings and community rallies about the need to rebuild St. Luke’s Hospital consistent with the needs of the neighborhood it serves. She noted that, although San Francisco Mayor Ed Lee was in discussions with CPMC over what services CPMC was going to provide at St. Luke’s and other areas in the city that he found lacking in their LRDP, the mayor’s $108 million demands did not include psychiatric services.
During the 8 July tour Buckley had explained the need for Acute Diversion Units (ADUs), in addition to more inpatient beds for the most critical patients, as alternative facilities for patients who don’t need the level of care provided by a psychiatric emergency room. He stressed the importance of clinical programs to manage stabilized patients in a controlled, but not locked, environment, along with preventative services and intensive case management to help break the cycle for patients who frequently end up in PES.
Buckley maintained that, while Sutter/CPMC has argued that hospitalization of the mentally ill is not the “current model,” for those brought in to PES who are deemed to be a danger to themselves or others, hospitalization is absolutely the initial recommended treatment. However, he noted that he didn’t see the City demanding Sutter/CPMC to contribute funding towards case-managed supportive services housing either. Such housing requires case workers in residential facilities who can monitor the patients, ensure that they are taking their medicines and making their mental health appointments and can intervene before a patient suffers an acute psychotic incident.
Commission President Olague asked what percent of patients are transferred to these alternative facilities and learned it was only about 20%. Dr. Buckley responded that, “Many patients end up in Single Room Occupancy hotels (SROs) when there are no other alternatives. It beats the street, but many don’t last long there. The leases are week-to-week,” leaving them without tenants’ rights and susceptible to being evicted and ending up homeless. President Olague said she was familiar with the week-to-week arrangements “It’s called ‘musical rooms’ and it’s illegal.”
Dr. Buckley explained that SROs are the lower end of the spectrum of support services with ADUs at the top, followed by intensive case management. He pointed out two patients whom the PES staff had been trying to send to an ADU recently, but there was no room, underscoring his call for the County to expand the entire spectrum of psych support services, not just inpatient beds.
Other psychiatrists at PES, including Dr. Jo Ellen Brannan-Rodriguez and Dr. Mark Farren, spoke during the July 8th tour to the lack of mental health facilities for children and adolescents suffering acute psychotic episodes. Dr. Farren noted, “They can end up mixed in with the adult population, including out-of control jail inmates who are brought here by Sheriff’s deputies when Ward 7-L, the jail psych ward upstairs, is full. They stay here until we find them a place — sometimes as far away as Sacramento, because there’s nowhere else!” In the past two years, Sacramento County Mental Health Clinic reduced their in-patient beds from 100 to 10 and the area emergency rooms have 6-8 patients strapped to a gurney waiting days for psychiatric evaluation.
Conditions at the SF General Hospital Jail Psych Unit
After an hour in PES, the commissioners went to the seventh floor of SF General Hospital to see Villela outside Unit 7L — the psychiatric unit for SF County Jail inmates requiring hospitalization. Dr. Villela said he has worked at SFGH for a total of 9 years and has been 7L’s medical director for the past several years.
Dr. Villela noted that, “The jails have become the ‘new asylums.’ They are facing the same thing PES is experiencing — both have sicker and sicker people coming in.” He said, “Patients used to stay in 7-L three to five days, but now they are staying longer, which is bad because then we can’t take more people into the unit and have to send emergency psych cases to PES. They have to be accompanied by two Sheriff’s deputies, which is very expensive and ties up PES. This is not a proper form of management.”
When President Olague asked why he thought the severity has increased, Villela replied, “PES isn’t able to keep up with the numbers of people. About 70% of people who come to PES are turned away, so only the sickest get in. And since fewer patients are meeting the higher standards set by the State of California for acute psychiatric care they end up stuck in PES or discharged into less acute facilities. But without sufficient case management or supervision they end up destabilized, in the streets again, picked up by the police and put back in PES.”
Lately, Villela said that he has seen a “rash” of chronic mentally ill people moving in and out of the jail unit and PES almost every month. Since jails can’t force mental health treatment on inmates, they go to 7-L, the designated treatment center for inmates needing mental health care. As 7-L is often full of seriously and chronically ill patients, such as serial arsonists, who can’t just be discharged to the streets, the waiting list of jail inmates needing mental health evaluations and treatment is growing. They may still be waiting, with unmet mental health issues, when they are ready to be released. With inadequate support, follow-up or supervision they often end up back on the streets and arrested.
Dr. Villela addressed Olague and Sugaya to the need for more inpatient beds and expressed his concern over the pending enactment of the federal order to transfer thousands of inmates from over-crowded California state prisons to over-crowded county jails. “Apart from the problem of housing them, what are we going to do with the ones who need mental health treatment?” asked Villela.
State Senator Warns of Additional Funding Cuts
At a 15 June meeting of San Francisco’s chapter of the National Alliance on Mental Illness (NAMI SF) California Senator Leland Yee warned of more looming cuts to mental health services. POC members Valerie Gruber, PhD, MPH, a psychologist who runs the Substance Treatment Outpatient Program at SF General Hospital, Cameron Quambeck, M.D., a San Mateo psychiatrist, POC President Geoffrey Wilson, POC Operations Manager Brian Tseng and POC volunteer Laura Dickson attended the meeting at the invitation of Dale Milfay, NAMI SF vice president.
Senator Yee opened with, “Today the State Senate passed their budget, cutting mental health services, education services and other services.” Yee, a former child psychologist, was the only Senator in Sacramento to vote against balancing the state budget by cutting mental health. “Too often I have seen that cuts in mental health services are never restored, with extremely negative consequences for some of those least able to represent their needs.”
Yee explained the State’s plans to shift the management of community mental health dollars to county control by mid 2013, eventually dismantling the State Department of Mental Health.
Pointing out that there is already a greater demand for money for services that can maintain existing mental health services, Dr. Gruber asked Yee, “How can counties constructively deal with the dramatic increase in responsibility for finding the funding for mental health services?”
Yee said the state has only discussed two possible sources of revenue to help the counties fund their community mental health programs: extending the “temporary” half cent sales tax increases, and increasing vehicle licensing fees. However, Yee expressed concern that this will create a great disparity in the provision of mental health services between counties.
Yee then discussed additional negative impacts on mental health services resulting from the federal government forcing the state to decrease prison population by transferring 40,000 minor offenders to county jails by the end of 2011. The responsibility for treating the mental health needs of these inmates will be borne by already overtaxed county public mental health systems.
POC Operations Manager Brian Tseng asked Yee if Sacramento was considering reclaiming any of the huge tax breaks the largest “non-profit” hospital corporations in the area get in exchange for purportedly providing charity care. “With certain non-profits making so much money they can engage in billion dollar hospital construction plans, couldn’t the government recover some of their tax breaks to help ease the strain on the budget for mental health services?” Yee said all non-profit hospitals are responsible for charity care and agreed that “The government is certainly in a position to ask more of these non-profits.”
Another attendee asked, “With timber, agribusiness, ports, tourism, silicon valley, oil, the movie industry and bio tech, California is not a poor state. Why is everything cut except for subsidies and tax breaks to corporations who made record profits last year? Is there any move in Sacramento to get funding to support vital services from wealthy corporations instead of cutting them?”
Yee said he had introduced a bill holding corporations to certain requirements in exchange for their tax breaks or the government would take back the subsidies. “The bill failed in the Senate,” noted Yee. “The reality is we don’t have a voice with enough power in Sacramento to raise the revenue. The demand has to come from the community.”
POC’s membership has vowed to continue organizing to assure that the City’s contracts and permits with CPMC meet San Francisco’s needs for medical and psychiatric care and that Sutter actually provides this charitable care. Anyone interested in joining this campaign should contact David at (415) 434-9335.