April 22, 2003 -- Plan to downgrade mental health facility causes uproar

From sfweekly.com
Originally published by SF Weekly
Apr 23, 2003 ©2003 New Times, Inc

Brain Storms A City Hall plan to downgrade S.F.'s only long-term-care
facility for the severely mentally ill has critics up in arms

BY LESSLEY ANDERSON

Two years ago, Donna Mateer lost her grip on reality. She was living in a
San Francisco board and care home, a private dwelling that provides limited
care for small groups of the mentally disabled. Residents can come and go as
they please, and are cooked for and cleaned up after by attendants who
usually aren't certified nurses or doctors. Despite their freedom, board and
care facilities have some house rules: Residents must be well enough to
regularly take their psychiatric drugs, and not present a danger to
themselves or others.

So when Mateer, a 45-year-old manic-depressive, kicked an employee during a
manic episode (which she says she doesn't remember), she was tossed out of
the board and care and taken to the emergency psych ward at San Francisco
General Hospital. After she was released, Mateer checked into a Holiday Inn
and began racking up hundreds of dollars in calls to expensive party-line
numbers and room-service bills for calamari. "I was convinced I was going to
be the first woman American president," remembers Mateer. "When I'm on a
manic high I'm so grandiose."

These days, Mateer's highs and subsequent lows -- a state in which all she
can do is "sit on the porch and smoke cigarettes" -- aren't as debilitating
as they once were. For the first time in her life, she has a steady job -- a
two-day-a-week gig working the coffee cart at Community Focus, a mental
health nonprofit on Market Street. She again lives in a board and care, and
feels well.

Mateer credits her improvement to the Mental Health Rehabilitation Facility,
a high-level treatment facility for the acutely mentally ill where she lived
for seven months following her stint at the Holiday Inn. The MHRF, or "Murf"
as it's known, is a locked, residential institution run by the City and
County of San Francisco. Operated as part of San Francisco General Hospital,
the 145-bed MHRF isn't just the city's biggest facility of its kind, it's
the only one. It's the sole San Francisco source of long-term housing for
schizophrenics, manic-depressives, and depressives whose lives have spun out
of control (about a third of the residents also are drug and alcohol
abusers). "The MHRF is a good place for people who can't handle it out
there," says Mateer.

Mentally ill people who are admitted receive intensive care from a large
staff that includes four psychiatrists, five primary care physicians, about
10 therapists, and more than 40 nurses. Since failure to take one's
medications is the No. 1 reason that mental patients lose their ability to
care for themselves, MHRF residents are given their meds by a licensed
nurse, and receive monthly drug regime reviews by a pharmacist.

By contrast, residents of board and cares typically self-medicate, and there
is little monitoring of the effectiveness of their drugs. If a board and
care resident refuses to take his meds, there's not much the staff can do
about it. At the MHRF, a staff psychiatrist can petition a judge for
permission to inject anti-psychotic drugs until the resident's symptoms
diminish and he can agree to take the medication himself.

But the MHRF may soon be no more. The Department of Public Health plans to
lay off all of the facility's employees in an effort to help bridge the
city's $350 million budget deficit. Under the DPH proposal, the MHRF will be
relicensed as a board and care and run by an as-yet-undetermined local
social services organization.

Scaling down the MHRF is expected to save the city $8.1 million a year,
according to local officials who expect to face further cuts as a result of
the state's burgeoning $34 billion deficit. But while overhauling San
Francisco's only long-term residential psychiatric facility for the severely
ill will produce obvious short-term savings, there may be less obvious human
costs.

The biggest question is what will happen to the 130 or so people who
currently live in the MHRF. In the DPH scenario, two-thirds of them would be
discharged to unlocked community residential programs. These include board
and care homes, short-term treatment facilities, single-occupancy hotels,
and so-called supportive housing. The latter are hotels, such as the Lyric
Hotel in the Tenderloin, that are leased by the city and staffed with a
handful of social workers to help mentally ill residents stay on track.

Some MHRF staffers and city mental health workers worry that many residents
aren't ready yet for life on the outside. To transfer them to less
restrictive settings with less staff oversight, critics say, will lead to
serious setbacks in more than a few cases.

"Nobody is going to be put out on the street," says Mozettia Henley, the
MHRF's program director. "How long they'll be successful at lower levels of
care ... is a big question mark."

Some fear that elimination of the MHRF's acute-care services will accelerate
what is known among mental health specialists as the "revolving door"
effect. That's the cycle in which a mentally ill person breaks down, the
cops are called, and he is taken to the hospital emergency psychiatric ward.
From there, the patient is transferred to the hospital's acute psychiatric
ward for two weeks, then released. But two weeks is not enough time for some
to get better; Mateer, for instance, went on her manic Holiday Inn spree
after being released from S.F. General. And so the door continues to
revolve. Without the MHRF to take in patients too sick for unlocked
facilities, supporters say, some of them will inevitably wind up on the
streets.

"There is a very real chance that people will slip through the cracks, even
with the best intentions," says Ted Stinson, chairman of the San Francisco
Mental Health Board, which advises city officials on caring for the mentally
ill.

The remaining third of the MHRF's residents -- those deemed too ill to move
to less restrictive settings -- would be shipped to privately run acute-care
facilities outside San Francisco. These institutions, known as Crestwood
Manors, are run by a Stockton-based company called Crestwood Behavioral
Inc., and are located in San Jose, Vallejo, Novato, and Fremont.

To defend the transfer of the MHRF's sickest residents out of San Francisco,
Department of Public Health officials cite a 1999 U.S. Supreme Court ruling
that mental patients should be able to live in less restrictive,
comity-based settings, rather than in locked hospitals, if they are
medically able to.

"My sense is that many of the [MHRF] clients -- the ones that didn't have,
say, high levels of medical complexity as well -- can benefit from a
different model of care," says Marc Trotz, the DPH's director of housing and
urban health. He says that although the new board and care MHRF will offer
few of the programs and activities of the old facility, it will nonetheless
provide a less restrictive setting for 145 people.

It is much harder to put a positive spin on the DPH's decision to transfer
42 MHRF residents to the Crestwoods, because that is literally a step
backward for the city. Before the MHRF opened in 1996, San Francisco paid
for its acutely mentally ill patients to live in the Crestwoods, just as it
will do after the MHRF is reconfigured. The MHRF was created specifically to
end out-of-town transfers of the severely mentally ill. San Francisco voters
passed a 1987 bond measure, Proposition C, to fund construction of the MHRF
as a more therapeutic and humane alternative.

"This long-term facility will permit patients to remain near friends and
families ... which will help hasten recovery," wrote then-Mayor Dianne
Feinstein in the 1987 voters' handbook.

Mental health experts say the most ill MHRF residents are likely to suffer
more if separated from relatives, friends, and local activities. Some
patients' family members don't own cars and could visit them in distant
facilities only sporadically. San Francisco's Ombudsman Program, a patients'
rights advocacy group, received seven calls in a week from MHRF patients
alarmed at the prospect of being sent away from the city, says director
Benson Nadell. And public hearings on the matter have been packed with
patients, their families, and other supporters.

One of those concerned is Arthur, 69, a MHRF resident with bipolar disorder
who preferred not to give his last name. He is among those being considered
for a transfer to the San Jose Crestwood. Arthur is a poet who writes about
ecological themes, adores Golden Gate Park, and occasionally gives local
readings. He proudly adds that he once starred in a local dramatic
production of The Fantasticks.

"They just don't have anything like that in San Jose," laments Arthur. "And
I would have to give up the park, which would doom me."

"It's not so much about leaving the MHRF for Crestwood, it's about leaving
San Francisco for San Jose," he explains. "Do you see the difference?"

Unlike the dreary stereotype of a medieval-looking, bars-on-the-windows
mental hospital, the MHRF is light and airy. Though it sits next to its
parent, General Hospital, on Potrero Avenue, the two facilities couldn't
look or feel more different. The older county hospital is Gothic-brick
outside and fluorescently lit inside. The MHRF is sleek and modern, with
plenty of windows. Inside, it has the feel of a college, accentuated by its
two gardens, computer room, gymnasium, and arts and crafts center.

The MHRF boasts a wide range of programs intended to train residents to live
independently in the outside world. There are classes in money management
and computers, in which residents can get an e-mail account or learn
Microsoft Word. Job skills can be acquired by working in the MHRF general
store, and residents learn how to buy a Fast Pass and ride the bus. Several
drug and alcohol treatment programs are available, ranging from one based on
abstinence to one endorsing "harm areduction" -- that is, teaching people to
be safe even if they continue to use drugs. There's even something called
"leisure counseling."

"Having spare time on your hands with nothing to do with it puts you at risk
to spiral down psychologically," explains MHRF nurse Peter Strauss.

The MHRF's rehabilitation model has been successful -- 90 percent of its
residents have returned to the community, and the average length of stay has
decreased from 18 to six months since the facility opened. The average
length of stay at the Crestwoods is longer. (By how much depends on whom you
talk to -- MHRF staffers say two years, Crestwood officials say as little as
seven months at some facilities.)

But MHRF's state-of-the-art offerings come with a high price tag.

"It's an expensive facility, I won't lie to you," says Jennifer Baity
Carlin, a MHRF substance abuse counselor. However, she says the MHRF is
cost-effective in the long run as it keeps people out of even more costly
emergency rooms.

"Reduced cost was not the issue [in 1987]. The budget, or the economy, was
at a boom time," says Program Director Henley. "And the generosity of the
citizens of the City and County of San Francisco prevailed."

But Prop. C provided money only for building the MHRF, not running it. City
officials claimed that its operating costs could be made up largely from
sources other than city funds.

"The facility would pay for itself, with Medi-Cal and private insurance
payments," argued then-Director of Public Health David Werdegar in the 1987
voters' guide. He was wrong, however. Medi-Cal, the joint state-federal
program that pays for health care for the poor, doesn't reimburse skilled
nursing facilities, as the MHRF is classified, with more than 16 beds.

To make matters worse, not long after the MHRF opened, its residents were
notified that they were no longer eligible for federal Supplemental Security
Income payments, since they were already under publicly financed care. The
bottom line: San Francisco had to bear nearly the entire cost of running the
MHRF itself. And it wasn't cheap: The facility cost $13.2 million in the
most recent fiscal year. Now, city officials have decided that San Francisco
simply can't afford a dream mental health facility any longer.

Housing the 42 sickest residents in out-of-city facilities like the
Crestwoods will cost only $759,400 a year, officials say. (MHRF staffers
charge that the Crestwoods provide "warehousing" rather than proper care.)
And patients who are transferred to board and care homes and other less
restrictive residential settings in San Francisco will be eligible for SSI
and Medi-Cal reimbursement.

Still, such financial fixes are not balm for people whose lives have been
touched by the MHRF. Piers McKenzie, a San Francisco fine art appraiser,
didn't know anything about the mental health system until he and his wife
watched their 22-year-old daughter descend into dementia last year. Behavior
they had written off as "flaky" -- dropping out of school, disinterest in
having a job -- deteriorated into something nightmarish. McKenzie says his
daughter became violently agitated, hearing voices, yelling, and breaking
things.

After a trip to San Francisco General Hospital, McKenzie's daughter was
placed in the MHRF, where McKenzie and his wife have visited her every day
for the past seven months. McKenzie says his daughter's improvement there
has been marked. She now takes her medications, can hold a conversation, and
has given her parents hope that one day she will be able to live a normal
life again. She is slated to move to a board and care soon.

"But if you don't have the MHRF, there is no place for people to go," says
McKenzie. "If it hadn't been for MHRF, I don't know where my daughter would
be."

With any luck, his daughter will remain well, and he'll never have to find
out.