San Francisco Hopes To Improve Care For People With Mental Illness Living On Streets

San Francisco Mayor London Breed has promised to tackle her city’s homelessness crisis, a vexing situation involving drug abuse and mental illness that is compounded by the city’s high housing costs. Breed has asked Dr. Anton Nigusse Bland, most recently the medical director for psychiatric emergency services at Zuckerberg San Francisco General Hospital, to help solve the problem.

In March, she appointed him to the newly created position of director of mental health reform. His main role is to help the city improve its mental health and addiction treatment for people experiencing homelessness.

“I had the opportunity being there on the front lines, providing services directly to clients, to better understand and appreciate when a person has that combination of homelessness, mental illness and substance abuse,” said Nigusse Bland. He has worked in several Bay Area county mental health systems, first as an integrated care psychiatrist with Alameda Health System, then as chief of psychiatry for Contra Costa County.

The mayor backed a new state law, SB-1045, which establishes pilot programs to expand the use of conservatorship — a controversial practice that allows the city to take people with mental illness or substance abuse issues off the streets without their consent and put them into treatment.

To identify the people most in need of services, city employees used data on the 18,000 residents in need of immediate shelter. They identified about 3,700 who were experiencing what Nigusse Bland calls the “trifecta” of homelessness, mental illness and substance use. Many of them have repeatedly visited ERs or been jailed multiple times in the past year.

Of those 3,700 people, 237 were identified as immediate priorities. Nigusse Bland said the key is coordinating care to get them into housing and services they may not know are available.

San Francisco is the only jurisdiction so far to create such a conservatorship pilot program, though the law also allows Los Angeles and San Diego counties to do so.

San Francisco officials also recently reached an agreement on how to allocate mental health funding for those with the most urgent needs. Their plan includes a 24-hour service center and an outreach team.

Nigusse Bland sat down last month with California Healthline at the San Francisco Department of Public Health in the city’s Civic Center, which has long been a hub of homelessness and open-air drug use, to talk about the daunting task facing him. His comments have been edited for space and clarity.

Q: What were some of your first steps when you took this job?

We had a couple of challenges ahead of us, one of which was being clear about who is affected by homelessness, mental illness and substance abuse and finding the root cause of why they’re having this experience right now. In this population, care coordination works, and you have to be very thoughtful about deploying evidence-based practices to get those services to those individuals.

One of the overwhelming assumptions about this group of individuals is that they’re all getting high on crystal meth, but we were surprised to learn that 95% of these people have an alcohol-related problem. The good thing is that there are many things we can do about alcohol.

Q: What services will be available to the 237 people you identified as having the most urgent needs?

Those individuals will receive an advanced care coordination team coupled with street responders, mental health specialists, a psychiatrist, and caseworkers who are actively reaching out to these people in the community.

If they are found in an emergency setting, we will go to that setting and help navigate them to a safe place, which might be a substance use treatment program, a mental health residential program or directly into housing.

Q: Allowing city officials to hold people against their will is controversial. What do you think about using conservatorship to treat people with mental illness or substance abuse disorders?

We have to be very thoughtful in the balance between autonomy and restoring a person’s dignity and health. It’s inhumane to allow someone to suffer on the streets with serious mental illness and substance abuse when there are alternatives available to them. In many of those cases, those individuals who are so severely affected may not even understand what’s happening to them at that moment. They’re struggling.

Through conservatorship, we have an opportunity to help restore that person’s capacity. I see it as an opportunity. In some cases, it can be the right thing to do to help that person get back on track.

Q: How will you get people the services they need given historically limited funding?

Our mayor has made a significant investment by adding over 200 new behavioral health beds into our pipeline with plans to add over 800 new beds.

We have commitments to increase the number of our intensive case managers, especially in mental health services for individuals with complex mental health and substance abuse issues.  We’ve made a commitment to reduce intensive case managers’ workloads to be able to meet the needs of these clients.

We want to make sure the ones most severely affected are getting into housing and get the support to stay in housing.

Q: How will you gauge success?

We should see changes in people experiencing homelessness, the amount of time they spend in jail and the emergency room, and their engagement in some kind of meaningful activity.

There are a couple of things that I think are going to make an impact, one of which is our Drug Sobering Center for those suffering the consequences of methamphetamine use. If someone appears confused, is having difficulty keeping their clothes on or yelling at someone, there’s a safe place that’s not jail, that’s not the emergency room, where they can recover and get counseling. And, if they’re ready, they can go into a treatment program as a next step.

That person doesn’t have to spend another night on the street and has the opportunity to get into services rather than having a jail record. And there’s the indirect impact of our emergency departments likely experiencing less crowding.

Q: What else should people know about this work?

Thirty-five percent of those 3,700 individuals in that trifecta are black and/or African American, a group that represents only 5% of San Francisco’s population, so they are disproportionately represented in the most vulnerable among us. We want to see an equitable San Francisco so everyone has a fair shot at wellness and recovery.

Sometimes that first opportunity isn’t successful and you might have to engage again to get that person on the right track, but what we know is that with every opportunity, they can make progress. It might be incremental, and it’s on their own timeline, but they can get better.