Thursday, December 20, 2007

Homelessness, Mental Illness, & Medical Costs

Interesting article in the December 18, 2007 San Francisco Chronicle about the high costs that homeless mentally ill persons impose on San Francisco:
Niels Tangherlini is willing to state the hard truths about San Francisco's street population. And he's doing it, even if it causes howls of protests from advocates for homeless people or from some city political leaders.

For example, Tangherlini strongly believes some severely mentally ill street people need "long-term, regular care. And if they don't want to accept that, we may have to impinge on their civil rights."

He also believes that, in some cases, just giving someone a room isn't the answer either.

"We hear that all the time," Tangherlini says. " 'All they need is housing.' I don't want to get into a war with the advocates, but I strongly disagree. We get some of these guys into supportive housing and they can't handle it."

And most of all, Tangherlini thinks that the current system of support, where a 911 call sends an ambulance rushing out to treat someone who is likely to be a "chronic inebriant," is an ongoing disaster. Some of those who call clearly need medical care, but many are using the ambulance and the Fire Department as a personal taxi to the emergency room. He says it is stressing the system, the care providers and the city's financial well-being.


A Chronicle story in 2005 praised Tangherlini's efforts and noted that between March 2004 and August 2005, a relatively small group of people - just 362 individuals - accounted for 3,869 ambulance trips to the hospital. The story estimated that at roughly $3,000 per pickup and visit to the ER, the cost to the city could be over $11 million.


On a visit to the emergency room at San Francisco General Hospital last week, staff nurse Judith Chavez walked up, unsolicited, to praise Tangherlini and the work he is doing.

But she then gestured around the crowded ER, where rolling beds with dozing patients lined the halls. Despite the efforts, "chronic inebriants" are still a huge problem.

"I see the abuse" of the emergency medical services, said Chavez, who estimated that on some nights, 70 percent of the beds are filled with chronic drinkers who are repeat visitors. "We don't have that much room here. We need to take care of the sick and wounded."

Spending a day with Tangherlini gives a sense of the scale of the problem. For example, during a nonstop day of calls, he visited a Sixth Street hotel where an extremely intoxicated occupant had already been placed in an ambulance. Tangherlini was familiar with the man, who lay on a stretcher in the back of the unit, awake but unresponsive.

"You know that you are at risk of losing this housing," Tangherlini said, looking into the man's eyes. "Does that worry you?"

There was no reaction.

"He's been telling me it is February of 1967," the ambulance technician said.

"What's his room look like?" Tangherlini asked.

"Like a glass recycler's dream," the tech said. "The floor is covered with Cisco's (a cheap fortified wine), 40s (cheap 40-ounce beer bottles), Royal Gate (vodka that sells for $1.75 a pint.)"

"And he did all this in four days," Tangherlini said.

The man is a "frequent flier," the term used by public health officials all over the country for someone who routinely uses ambulance and ER services. Tangherlini says the man took 21 ambulance rides in the previous month and was just released from the hospital two days earlier.

"We've given him supportive housing," he says. "We've given him a caseworker. He's gotten both barrels of community-based care. It isn't working. This is the population that will break your emergency system. There is no more inefficient way to detox someone than to do it in the hospital."
Here's some painful truths from those on the front line. Mental illness and substance abuse are strongly correlated, because people with serious mental illness often intoxicate as a form of self-medication. It is often only a short-term solution, and many of the common intoxicants lead to other serious problems, as this article points out.

The inability to admit that mental illness is a major part of what causes homelessness in San Francisco (and a lot of other big cities around the country) means that the leftist screeching about "housing" ends up obscuring that for many of the homeless, having housing only solves one small part of the problem--and then, only as long as they can manage a place of their own.

The pleasant little theory about deinstitutionalization was that the severely mentally ill would end up back in their communities, receiving community-based psychiatric treatment. It didn't happen, because many of the mentally ill are not sufficiently well--or at least, not consistently so--to hunt up all the social services that they need to keep from freezing to death, or dying of pneumonia, or getting murdered by either other mentally ill homeless people, or common thugs looking for a thrill. As much as the mental hospitals of the 1950s were denigrated as horrible institutions, they at least simplified the providing of basic services to many of the most seriously disturbed parts of our society. What we are doing today in places like San Francisco is not only cost inefficient, it is profoundly inhumane.

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