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Old 04-27-2003, 10:31 AM
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Default S.F. mental ward is budget victim

S.F. mental ward is budget victim
Critics decry 'unethical' discharge of severely ill patients

Kathleen Sullivan and Katherine Seligman, Chronicle Staff Writers Sunday, April 27, 2003


A San Francisco psychiatric facility for the severely mentally ill is preparing to close because of the city's budget crisis, and staff members say patients are already being discharged despite the risks to their well-being.

City health officials want the Mental Health Rehabilitation Facility, the only center of its kind in San Francisco that admits long-term patients who need locked wards, to reopen as a board-and-care facility. The officials argue that such a center is more needed and would qualify for federal subsidies.

In advance of the proposed June 30 shutdown, the 150-bed, state-of-the-art facility at San Francisco General Hospital has begun transferring some clients to privately run treatment centers out of the city -- a move, critics say, that could isolate patients from family members and deny them adequate care.

"It's totally unethical," said Terry Ellis, director of rehabilitation for the MHRF. "It's totally inappropriate . . . but they just want them out of here."

The proposed closure, which must be approved by city supervisors and the mayor, has ignited a controversy at City Hall, which is trying to weigh the budget crisis against the demands of a financially strapped mental health system.

Supervisor Tom Ammiano has called for a hearing before the Board of Supervisors on Tuesday and asked the city attorney's office to determine whether it's legal to transform the facility into a board-and-care program.

Even San Francisco writer Danielle Steel, calling herself "a parent who lost a mentally ill child," has gotten involved. In a letter to top health and city officials, Steel has begged them to reconsider.

Ellis points out that she has never seen so many people discharged at one time: "Maybe there were 10 discharges a month. We've had 40 in the last month. They are trying to close all this down so it's a done deal."

But Liz Gray, who oversees patient placement for the Community Behavioral Health Sciences division of the San Francisco health department, said: "We are not kicking anybody out."

She attributes employee complaints to the fact that workers at the facility stand to lose their jobs or be reassigned because of the budget crisis.

A union representing workers at the facility has filed a lawsuit seeking an injunction to stop the city from converting the facility. A hearing in San Francisco Superior Court is scheduled for Friday.

"If I were in an organization that was changing its status and that would affect me personally, then I would be upset," Gray said. "I think a lot that is happening (with employees) is not unexpected or unanticipated."

A review by Ellis of the facility's discharge statistics in 2003 shows that:

-- In January, 13 people were discharged -- none to locked facilities.

-- In February, 15 people were discharged -- none to locked facilities.

-- In March, 21 people were discharged -- four to locked facilities.

-- In April, 40 people were discharged -- 20 to locked facilities and five to San Francisco General Hospital's acute psychiatric care ward.

Ellis said that under normal circumstances, it was rare for the facility to discharge patients to locked facilities. "We get them better so they can go to other places," she said.

Gray, however, said that only the most seriously ill -- all of them legally deemed not able to make decisions for themselves -- were transferred to locked facilities.

The others released went to their families, board-and-care homes or residential hotels, Gray said, and were part of regular discharge plans that had nothing to do with the proposed shutdown.

Gray said she hopes some of those patients left behind will be housed in the new board-and-care facility when it reopens.

But Ellis and other staff members worry that most of the patients will be gone by the time that happens. They say the exodus from the hospital has swept up not just the most severely ill, but also those who need less intense care and, given time, could have been housed in the community. Two of the program's five units already have been closed, employees said.

The San Francisco facility opened in 1996, nine years after city voters approved a $26 million bond measure in response to problems created when the state began closing mental hospitals, a move that sent many discharged patients back to their home counties.

The facility was seen as a much-needed, high-quality community approach, one that would serve the needs of patients in the county and help pave the way toward reintegrating them with family, friends and jobs.

The program, one of few such facilities in the state to be run by a county, was supposed to generate enough revenue to pay for itself. But no one anticipated the depths of the current budget crisis.

Complicating matters is a federal law that excludes certain mental health facilities with more than 16 beds -- like the facility in San Francisco -- from getting reimbursement from the federal government.

In the public health department, director Mitchell Katz and top administrators decided that changing the facility would be a logical way to reduce expenses. Katz said the county foots the entire $8.2 million bill for the facility. A board-and-care program would not only be less costly, it could qualify for federal reimbursement.

"We are actually being very creative out of a situation that started as a budgetary concern," said Marc Trotz, director of housing and urban health in the public health department, who would oversee the new facility. "It's a chance to have a 21st century facility that is in step with how to treat people with serious mental illness."

Ideally, Trotz said, the county would keep both facilities -- a secure ward with fewer beds for the severely mentally ill and a less restrictive board-and- care home. The county does not need all of the beds at MHRF, he said, but does need long-term placement options for people who are less severely ill.

The controversy in San Francisco has stirred up a long-running debate about whether the severely mentally ill should be treated more in community settings or locked away in hospitals.

"It's not a simple story," Trotz said. "There are two sides to this coin. Given the advances in medicine and law, this is the way that many people in the field think mental health housing should be moving."

Times have changed, even in the past seven years, said Gray. The newest model of care, she said, "is called recovery."

"It is a consumer model," she said. "It says we can recover from our illnesses. We can return to school and jobs. We need to support mental health organizations to help us do that."

Belinda Lyons, executive director of the Mental Health Association of San Francisco, said her advocacy group supports using the least restrictive level of care and moving people into community settings. She said that patients should not be in locked facilities if any other option is workable.

But Lyons said she is concerned about how the changes at the San Francisco facility will be implemented and the adequacy of centers where the severely mentally ill are being transferred.

Gray said the county has had contracts in the past with out-of-city facilities that provide high-quality care. Even so, some workers in San Francisco worry about how patients will fare with all the turmoil of changing settings.

"We're supposed be be providing quality mental-health care to our patients and right now, we're not doing that," said Jennifer Baity Carlin, a psychiatric social worker at the facility for nearly three years.

"Right now, we are traumatizing the patients by closing the place down, by moving them out of their community, by creating all of the confusion and upset that comes when patients are moved from unit to unit, from floor to floor as they're on their way out of the facility."

Piers Mackenzie, whose 22-year-old daughter is at the San Francisco facility, said moving patients to private centers out of the county will make it hard for some low-income families to visit them, especially if they don't own cars and must rely on public transportation.

Mackenzie, a fine arts appraiser and auctioneer, has organized a group -- Friends and Family of the Mental Health Rehabilitation Facility -- to fight to keep it open. Last week, he led a rally on the steps of City Hall.

"A vital part of the treatment of a resident is frequent, if not daily family interaction and support," he said. "Imagine if you send patients to Napa or Vallejo or San Jose or Modesto. How are those families going to get there?"

Peter Straus, a recreation therapist at the facility, said he doesn't believe the rehabilitation programs in locked treatment centers in other counties are as good as the one in San Francisco.

"And those other locked facilities don't have enough social workers to do all the legwork necessary to set up a good discharge," he said.

"They don't necessarily have the same connections to hook up patients with good, follow-up case management, which is extremely important in terms of them succeeding in the community -- and not ending up on the street, dead, in jail or back in the hospital again."

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