For a number of years different agencies have worked to build a continuum of care that focuses on providing services in the community at the lowest and least restrictive level of care in order to minimize the use of higher levels of care such as psychiatric emergency services and inpatient hospitalization. Nonertheless, Supervisor Chris Daly and the community have identified a serious gap in the continuum at the level of non-residential 24-hour services. In order to help fill this gap, Supervisor Chris Daly and the community have submitted this proposal to the State of California and the San Francisco Board of Supervisors to build a 24-hour drop-in center.
Consequently, there continues to be an absence of after-hours psychiatric services in San Francisco, with the exception of Psychiatric Emergency Services at San Francisco General Hospital. Individuals who experience psychiatric crisis after hours are dealt with by the police, and when necessary taken to the hospital. In fact, one in four police calls are responses to individuals in psychiatric crisis, or individuals “acting with bizarre behavior”, with the overwhelming majority occurring after hours. This is counter-therapeutic, and sometimes leads to permanent distrust of psychiatric services on requested 24-hour community services, in the report “Locked Out” by the Coalition on Homelessness. One other specific need that has been identified by the Coalition on Homelessness and others in the community is a “Warm Line” telephone service that would be staffed by professionals and/or peer counselors and would provide support and impending crisis situation. Suicide Prevention currently provides telephone crisis services, but only through it’s Suicide Prevention Service.
The planning process for the 24-hour drop-in center was initiated by Community Mental Health Services and the Mental Health Board in November 2001 and taken up again by Supervisor Daly in October 2005. The goal of this process was to develop a proposal for an after-hour PRE-CRISIS drop-in center with minimal barriers to accessing the center’s services as advocated for by the Mental Health and Substance Abuse Workgroup of the Coalition on Homelessness. The proposed center would seek to decrease the number of acute mental illness episodes that reach the crisis stage by offering a carefully designed service package to achieve this goal.
The proposed drop-in center would seek to achieve the following outcomes developed by the planning group.
- Decreased police intervention in acute mental illness episodes and involuntary (5150) hospitalization.
- Reduced utilization of Psychiatric Emergency Services.
- More crisis episodes that are “nipped” in bud or treated early.
- Availability of psychiatric medication for clients already on anti-psychotic medication, those needing to start anti-psychotics, or for acute anxiety.
- Decrease the number of homeless deaths and/or psychiatric related deaths.
- Decrease number of deaths by legal intervention (“suicide by cop”).
- Save money by reducing hospital and emergency costs and utilization.
- Decrease the number of 5150’s and involuntary commitments, and incarcerations in jails.
- Increase the number of consumers who are actively engaged in treatment.
- Increase the number of successful links to mental health services.
- Increasing the flexibility and variety of services in the community-based safety net.
In order to achieve these outcomes the planning group decided that the following essential services should be provided. A complete rank-ordered list of the services that would contribute to achieving the desired outcomes is also available.
- After-hours services-the program could minimally be located at an existing service site for evenings, nights and weekends, or maximally be a stand-alone program with 24-hour/7-day a week services.
- Peer counseling and self-help is essential to increase the ability of the staff and program to establish a link to potential clients and start the engagement process.
- Access to psychiatric medication for clients already on anti-psychotic medication, those needing to start anti-psychotics, or for acute anxiety.
- Welcoming and supportive-the physical and social environment needs to be welcoming and supportive and clients need to be able to feel safe and secure.
- Easily accessible to most potential clients by foot or bus.
- Crisis intervention and stabilization-professional and peer staff need to be professionally trained in crisis intervention and stabilization.
- Physicians and nurses and case management-medical staff are necessary for proper assessment and the administration of medications.
- Culturally competent services/staff/volunteers-all staff connected to the program need to be culturally competent.
- Prepared for crises-the staff must be trained in crisis de-escaltion techniques and any other techniques which minimize the need for police or other control measures.
- Specific focus on the homeless culture-staff must be trained and experienced in the culture of those who are homeless and living on the streets.
- Peer staff and licensed clinical staff-an appropriate and balanced staff mix is critical tot he program and includes both paid and volunteer staff who are both professional and peer trained.
- Harm reduction service model-the program must be fully committed to a harm reduction model that emphasizes working with clients “where they are at” and seeking to reduce potential harm through a variety of strategies.