Updated March 2015
In 2001, a group of firefighters and emergency physicians in San Francisco came together to discuss ways of making the EMS system more efficient. It didn’t take long to identify one of their biggest challenges: homeless serial inebriates. While many systems know this group of indigent and often uninsured patients all too well, in San Francisco, the problem was particularly onerous.
The city not only has a large homeless population, but the dubious distinction of having more places to buy alcohol—liquor stores, bars, convenience stores—per capita than any city in the nation, says John Brown, M.D., an emergency department physician at San Francisco General Hospital and medical director for San Francisco EMS Agency, which oversees EMS providers in the city. What’s more, reimbursement rates are low, with the city collecting on only 30 to 40 percent of emergency transports.
A six-month study of the city’s chronic users of EMS, or those picked up four or more times in a month, found that about 75 percent are chronic public inebriates. “Usually what happens is these patients can’t ambulate without assistance, so they’re taken to the emergency department, evaluated, sobered up and discharged to the street, where the vicious cycle starts again,” Brown says. “It ties up the emergency department and the ambulances. And the patients don’t get any better.”
With funding from the city and local hospitals, the San Francisco public health, police and fire departments, in conjunction with the San Francisco EMS Agency, launched a serial inebriate pilot program in 2004 to combat the problem. The first step was to convert a portion of a building that was being used as a homeless drop-in center into a sobering center.
Located in the city’s Tenderloin, a downtown neighborhood where the homeless congregate that’s near shelters, public transportation and detox centers, the sobering center has 12 beds and is staffed mainly by licensed vocational nurses. With an annual budget of about $800,000, the center is designated for alcoholics who otherwise have no pressing medical issues. (The other part of the building became a medical respite center. With an annual budget of about $2.2 million, medical respite serves homeless patients after discharge from the hospital for medical problems not related to substance abuse.)
When first responders are called to pick up a serial inebriate, they follow specific protocols to determine who is eligible to be taken to the sobering center instead of the emergency department. Patients must be intoxicated from alcohol alone, not other drugs. They must be able to walk with assistance, have no external evidence of head injury and have vital signs that fall within specific parameters. If those criteria are met, responders have two choices: drive the patient to the sobering center themselves, or call Mobile Assistance Patrol, a van service contracted with the city to transport indigents to shelters, food banks, the sobering center and other locations where they can receive services.
During the first six months of the program, there was no shortage of customers. Nearly 600 inebriates were taken to sober up instead of using valuable and expensive hospital beds. Today, the center helps from 1,200 to 1,400 individual patients a year, for a total of 2,500 to 3,000 encounters.
Successes and challenges
One of the important, early successes of the program was proving that firefighter/paramedics and EMTs could correctly identify who should go to the sobering center. Many inebriates have other issues, including head injuries, subdural hematomas, co-intoxication with other substances such as opiates or methamphetamines, severe skin infections, chronic untreated high blood pressure or diabetes, skin infections or HIV. Occasionally, patients taken to the sobering center had to be transferred to the hospital when other medical conditions emerged as the person sobered up, Brown says, but responders most often got the diagnosis just right.
While perhaps good news for the emergency departments, the story doesn’t end there. Homeless inebriates are among the most intractable, difficult-to-treat patients, with alcoholism often accompanied by mental health and behavioral issues, lack of education and other chronic illnesses. “This is the bottom,” says Tae-Wol Stanley, medical respite and sobering center program director. “If you are a street drunk, you have fallen through every safety net there is.”
Shannon Smith, a former EMT and a registered nurse who is the sobering coordinator, adds: “When they’re picked up, they’re in a raw state of filth. They often have lice and are covered in feces and urine. They can’t engage for the first two or three hours. It’s not until three to five hours that they become more alert and you can start talking to them.”
That’s the point at which the challenge for staff begins. If patients are willing to consider rehab—and that’s a big if, since many of them aren’t—staff have to get them admitted into a medical detox center in short order, usually within two to eight hours, before potentially dangerous symptoms of withdrawal set in. Detoxing from alcohol can be life-threatening, causing seizures, hallucinations and spikes in blood pressure, leading to heart attacks or stroke. Because the sobering center is staffed by LVNs, staff can give water and electrolytes, but they can’t handle medical detox or administer medication, whether it’s insulin to diabetics or benzodiazepines to counteract some of the side effects of withdrawal.
The process isn’t as simple as dropping off the willing at a medical detox center, Smith says. First off, detox centers don’t always have beds available; what’s more, the facilities require tests for tuberculosis, X-rays and other paperwork that can be difficult to get completed in, say, the middle of the night. If they can’t get patients admitted to detox fast enough, patients have to be transported back to the emergency department, although most of the time they manage to avoid that, Smith adds.
And despite their best efforts, the number of serial inebriates taken to the sobering center and kept out of a hospital is, in some respects, just a drop in the bucket given the scope of the problem. The sobering center also isn’t directly alleviating the burden on EMS to transport patients, although the hope is that fewer serial inebriates on the streets will eventually translate to fewer 911 calls to pick them up.
Staff at the sobering center are well aware that many patients will simply sober up and leave, only to return again soon—sometimes even later that day. In fact, their records show a mere 178 people are using 70 percent of the sobering center’s resources. “We wanted this to be more than a glorified drunk tank,” Stanley says.
Next steps
In the summer of 2009, the public health department and other stakeholders formed the High Utilizers of Medical Services program to look for other ways to deal with the issue. Their research showed that each high user accounted for $60,000 a year in uncompensated care—and that only accounts for short-term crisis care, such as ambulance transport, emergency department visits, psychiatric emergency services, sobering center services and medical detox. None of those costs are directed toward treating alcoholism over the longer term.
Yet some users cost far more than that. The most extreme frequent user was picked up 49 times in one month, says Maria X. Martinez, deputy director of San Francisco Public Health Department’s community programs.
One solution being discussed is increasing staffing so that the sobering center can do medical detox. “What I would like to see at the sobering center is the ability to give medications, which is something they can’t do right now,” Brown says.
Another goal is to offer more complete case management to serial inebriates by partnering with county mental health services and other agencies. Serial inebriates need alcohol rehab, access to primary care, and supportive or supervised housing to keep them from ending up back in the emergency department.
“Public inebriates often have a lot of fingerprints on them. They usually come up in a lot of databases—shelters, the emergency room, the courts or the mental health system,” Smith says. “We’re trying to find ways to move them off the treadmill.” The goal is to have a process for assigning inebriates to a case manager implemented by the end of the year.
And despite the obstacles, there have been successes, according to Stanley: Some patients have told them that being taken to the sobering center made a difference in their lives.
“If we can get 100 people off the treadmill of ambulance rides, injuries and hospital visits, that can save millions and millions of dollars a year,” Stanley says. “Targeted work with this population can be so effective in so many ways: quality of life for the patient, quality of life for the city. Nobody wants to step over a drunk in Union Square. It can save the city money and save access to emergency services.”
