Cutting from the bottom

Pub date June 8, 2010

By Alex Emslie

When Mayor Gavin Newsom unveiled his proposed city budget on June 1, he downplayed the severity of cuts to the city’s Department of Public Health, noting that they amounted to less than 2 percent. But if Newsom’s uneven program chopping becomes a reality, critical social services for some of San Francisco’s poorest and most vulnerable residents will be cut by almost one-third.

The DPH was able to shrink its budget by nearly $31 million, according to a budget proposal currently before the Board of Supervisors, in part by slashing community nonprofit clinics providing outpatient mental health services to some of San Francisco’s most difficult to treat mental health cases.

“It’s very possible you could see more people who are homeless, people who are homeless not getting as much care — they’ll be sicker,” said Dr. Eric Woodard, medical director of psychiatric emergency services at San Francisco General Hospital. “And you could reasonably expect more deaths on the street to occur.”

State and federal matching funding to the DPH dwarfs the amount of money the department receives from the city. What isn’t spelled out in Newsom’s budget is that every dollar cut by the city results in more than another dollar lost in federal funding for social services.

The DPH proposed a nearly 9 percent cut to outpatient community-based health services, and an 11 percent cut to residential inpatient services to meet the mayor’s request that all city departments submit a 30 percent budget reduction to his office. Newsom reversed the proposed cuts to residential services but kept the outpatient cuts.

“I believe in the efficacy of residential [treatment],” Newsom said during his budget unveiling. “I believe there are a lot of question marks around outpatient drug treatment.”

But the cuts affect more than just outpatient drug treatment. While many of the clinics that were cut focus on treating mental illnesses, they are funded through the DPH category that includes substance abuse treatment. Newsom’s office declined to answer our inquiries about the reasons for and implications of his cuts, referring us to DPH.

Walden House CEO Vitka Eisen, whose organization serves people suffering from mental illness and substance abuse in inpatient and outpatient clinics, said she was relieved that residential funding was added back. However, she is concerned about the proposed $4.1 million cut spread across several nonprofit outpatient services.

“There’s a very large cut to outpatient services citywide, and that’s obviously problematic because outpatient services are an important part of our system of care in the city,” she told the Guardian. “You can’t really cut one or the other.”

DPH Community Behavioral Health Services Director Dr. Robert Cabaj is hoping the Board of Supervisors will restore some of the cuts to outpatient clinics. “Unfortunately, they [the Mayor’s Office] left these in,” he told the Guardian. “I’m not sure why — I’m not sure what the mayor was thinking at the time.”

Citywide Case Management and Community Focus, an outpatient clinic serving some of San Francisco’s most severely mentally ill, is one of the hardest hit nonprofit clinics in the mayor’s proposed budget. The agency will lose $1.22 in federal funding for every $1 cut from the city, division director Dr. David Fariello said.

That’s how its 15 percent, $1.3 million cut proposed by the DPH and accepted by the mayor, ballooned into a 33 percent, $2.8 million loss for one of the city’s most comprehensive and best-performing community behavioral health services.

Citywide, at 982 Mission St., boasts the facilities, network, and location to serve one of San Francisco’s most vulnerable populations. The typical Citywide client suffers from schizophrenia, bipolar disorder, borderline personality disorder, or severe depression. They are likely homeless, grappling with substance abuse, and many have posttraumatic stress disorder.

Citywide employees, doctors, and administrators, as well as physicians from outside the clinic, speculate that cutting outpatient mental health services in a city with one of the highest per capita populations of mentally ill homeless people will ultimately cost the city more money than it saves now. Use of expensive city services like psychiatric emergency rooms, jails, police, and ambulance could all rise.

“Frankly, a lot of these budget cuts do not seem to be very well thought out in terms of what the real cost is going to be,” Woodard said. “If you look into the not very distant future, you’re going to incur costs that are probably much greater than your savings were initially by making the cuts.”

Cabaj said that past funding cuts haven’t resulted in higher use of psychiatric emergency services because the DPH prioritizes funding for the most severe cases and screens for those who could possibly be moved into cheaper services. Citywide clients are consistently high users of San Francisco General Hospital acute inpatient psychiatric care, at an average cost to the city of $1,200 per patient, per day, if they don’t have insurance or Medical benefits.

Many end up in costly in-patient psychiatric care facilities or are arrested and land in the city’s Behavioral Health Court, which hears cases in which defendants have been diagnosed with a mental illness that is suspected of being a factor in their crime. More than 70 percent of the Behavioral Health Court’s mandated treatment slots are at Citywide.

“We can manage behaviors that get people thrown out of every other clinic in the city,” Fariello said. “Where is that capacity going to be picked up? These are not clients who, if they don’t get treatment, maybe their doctor will give them some medicine and it’ll be OK. These are clients who are going to continue to be high users unless we intervene.”

Citywide figures show a 40 percent decrease in violent reoffenses for clients referred to their clinic from the Behavioral Health Court. Nearly three-quarters who were homeless are able to maintain housing, and more than 25 percent of clients who were frequent users of inpatient psychiatric services have stayed out of the hospital.

“Citywide really is one of the best,” said Woodard, who works with Citywide’s Linkage Team to stabilize patients from SFGH’s psychiatric emergency room. “They provide excellent care for these really fragile, very ill patients. I would say of the community programs, they’re really at the top of the list.”

Fariello estimates having to reduce the 1,035 clients receiving treatment at his clinic by 400 if the cuts are finalized. He may have to scale back some of his clinic’s innovative and successful categories of service — such as employment support and dialectical behavioral therapy, a highly specialized form of therapy with proven success in treating borderline personality disorder. Citywide has the largest DBT team in San Francisco.

Citywide administrators are baffled by DPH’s decision-making process, given that it serves the city’s sickest, poorest, and homeless — characteristics that should have reduced its cuts, according to the department’s priorities outlined in its budget reduction proposal.

Since founding the agency nearly 30 years ago, Fariello has worked with the city to implement innovative techniques in treating San Francisco’s highest users of expensive psychiatric emergency services. And it has been consistently successful. In a review last year of 15 similar programs conducted by the DPH, Citywide received an average 92.1 out of 100, the highest score. It scored a 4.0 out of 4.0 on another recent program review.

Several divisions within Citywide contribute to its inclusive approach to mental health services. Citywide’s forensics program works exclusively with clients involved in the criminal justice system. Community Focus provides culturally sensitive therapy in several languages. The Linkage Team stabilizes emergency psychiatric patients from SFGH.

Employment support for Citywide clients helps them get and retain jobs, emblematic of the entire agency’s goal of treating clients as complete people, not just mental health patients. “What we’ve found out is that people who have an investment in purposeful activity have an investment in getting better,” Fariello said. “A lot of clients have a notion that their career is being a mental health client. What we’re trying to do is change that.”

Citywide supported employment services supervisor Greg Jarasitis told a story of one client who said she liked her job as a bookkeeper because while she was at work she felt like a “normy,” then added: “These are people who have been marginalized for so long.” *

Get involved: The Board of Supervisors holds a public comment hearing on the deep proposed health cuts, as state law requires, June 15 at 3 p.m. in Board Chambers at City Hall. The board’s Budget and Finance Committee departmental hearings for the DPH are scheduled for June 21 and June 28.