Report 2019-119 Recommendation 7 Responses

Report 2019-119: Lanterman-Petris-Short Act: California Has Not Ensured That Individuals With Serious Mental Illnesses Receive Adequate Ongoing Care (Release Date: July 2020)

Recommendation #7 To: San Francisco Department of Public Health

To ensure that it connects patients who have been placed on multiple short-term holds to appropriate ongoing treatment, San Francisco should, by no later than August 2021, adopt a systematic approach to identifying such individuals, obtaining available mental health history information about these individuals, and connecting these individuals to services that support their ongoing mental health.

Annual Follow-Up Agency Response From September 2023

Mental Health Sn Francisco created an Office of Coordinated Care (OCC) to centralize care coordination efforts, improve access to care and behavioral health linkages, and support individuals making transitions between levels of care. OCC launched a team in January 2022 that supports individuals exiting an LPS hold and connecting to appropriate levels of behavioral health care. In November 2022, the OCC moved into an integrated electronic health record with our public hospital, Zuckerberg San Francisco General Hospital (ZSFG), which houses the county's Psychiatric Emergency Services. This move was foundational to our work on systematic identification and planning for individuals exiting 5150WIC holds and allowed OCC and ZSFG staff, in conjunction with Department of Public Health data and IT teams, to create a daily report identifying all individuals placed on 5150WIC holds and summarizing their connections to behavioral health care. Over the last year the OCC has expanded its centralized triage and tracking functions with a goal of increasing rate of follow up. OCC has also added additional field-based teams to support the work of engaging with individuals at high level of need and with multiple system contacts, including street-based teams and teams focused at shelters and permanent supportive housing sites.

The Department of Public Health has continued to work with all local hospitals to systematically identify individuals existing a 5150WIC hold and fully implement SB929 and AB2242.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

Annual Follow-Up Agency Response From December 2022

Mental Health SF creates an Office of Coordinated Care (OCC) to centralize care coordination efforts, improve behavioral health linkages, and support individuals making transitions between levels of care. OCC launched a team in January 2022 that supports individuals exiting an LPS hold and connecting to appropriate levels of behavioral health care. In November 2022, the OCC moved into an integrated electronic health record with our public hospital, Zuckerberg San Francisco General Hospital (ZSFG). This move was foundational to our work on systematic identification and planning for individuals exiting 5150WIC holds and allowed OCC and ZSFG staff, in conjunction with Department of Public Health data and IT teams, to create a daily report identifying all individuals placed on 5150WIC holds and summarizing their connections to behavioral health care. In the next year the OCC will add more staff and the Department of Public Health will work with all local hospitals to systematically identify individuals existing a 5150WIC hold to support establishing or reestablishing planned behavioral health services.

Additionally, there is a team that is dedicated to supporting individuals seen by the Street Crisis Response Team (SCRT), a specialized 24/7 non-law enforcement response to behavioral health emergencies that diverts individuals away from emergency rooms and criminal justice settings into care. The SCRT OCC team prioritizes individuals who are placed on or have a history of being placed on a 5150WIC hold to ensure that a robust plan is in place prior to discharge.

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

We appreciate the department's update on its continuing efforts to implement this recommendation. We look forward to receiving the department's next annual update following its expected completion of those efforts in December 2023.

Annual Follow-Up Agency Response From October 2021

Mental Health SF creates an Office of Coordinated Care (OCC) to oversee behavioral health linkages, which is a priority for planning and implementation. OCC will provide systematic behavioral health care coordination and support linkage to appropriate levels of care, prioritizing people who are exiting an LPS hold. There is currently a team that is dedicated to supporting individuals seen by the Street Crisis Response Team (SCRT), a specialized 24/7 non-law enforcement response to behavioral health emergencies that diverts individuals away from emergency rooms and criminal justice settings into care. The SCRT OCC team prioritizes individuals who are placed on or have a history of being placed on a 5150WIC hold to ensure that a robust plan is in place prior to discharge. Full implementation of OCC is pending hiring.

DPH has met with the Hospital Council of Northern California twice (June and August 2021) to discuss revising Designated Facility Agreements that would allow for enhanced data sharing, care coordination, and treatment planning for individuals exiting a hold, with particular attention for those with repeated involuntary holds. We requested that hospitals across San Francisco identify a point of contact for coordination by August 2021. At the time of this report, we have received a point for contact from one facility. We have informed hospitals that our goal is to partner with hospitals to update agreements, with their input, by Spring 2022 (with possible delays due to ongoing COVID response/surges and/or delays in response from hospital leadership).

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

The department's response and supporting documentation it provided demonstrate that San Francisco has taken a proactive approach to connecting individuals to appropriate mental health care. As the department notes in its response, it is still in the process of implementing components of that approach, including its agreements with hospitals to share data and coordinate care for individuals who are placed on involuntary holds for mental health treatment. Therefore, we consider this recommendation partially implemented and look forward to assessing the outcome of San Francisco's continued efforts when it provides its next update.

1-Year Agency Response

Mental Health SF legislation creates an Office of Coordinated Care (OCC) to oversee behavioral health linkages and was discussed in our previous reports. The OCC continues to be an implementation priority. OCC currently has a team of clinicians and peer health workers that provides dedicated support to individuals who have been served by the Street Crisis Response Team (SCRT), a non-law enforcement response to behavioral health emergencies in public spaces. As of August 2021, the crisis teams will provide 24/7 city-wide coverage, which allows for a specialized and humanistic response to behavioral health crisis and diverts individuals away from emergency rooms and criminal justice settings into behavioral health care. The OCC team that provides follow up has frequent contact with individuals who have a history of being placed on a 5150WIC hold and prioritizes individuals who are placed on a hold by the SCRT team to ensure that a robust treatment plan is in place prior to discharge.

In addition to these efforts, The Department of Public Health has met with the Hospital Council of Northern California to discuss revising existing Memorandums of Understanding (MOU) that would allow for enhanced data sharing, case conferencing, and joint treatment planning for individuals exiting a hold, with particular attention to those who have had repeated involuntary holds. We have requested that all San Francisco hospitals identify a point of contact to coordinate enhanced MOU's and share information on individuals who have multiple involuntary holds by August 2021.

California State Auditor's Assessment of 1-Year Status: Partially Implemented

The department's response and supporting documentation it provided regarding the Street Crisis Response Teams demonstrate that San Francisco has taken a proactive approach to connecting individuals to appropriate mental health care. However, because the department has reported that its Street Crisis Response Teams only respond to calls that do not demonstrate a significant safety concern, these efforts alone will not fully ensure that individuals who are placed on involuntary holds when they pose a danger to themselves or others will get connected to the care they need. To the extent San Francisco succeeds in also improving coordination with hospitals, its approach should ensure better care for individuals not treated by the Street Crisis Response Teams. Therefore, we consider this recommendation partially implemented and look forward to assessing the outcome of San Francisco's additional efforts when it provides its annual update.

6-Month Agency Response

Mental Health SF legislation creates an Office of Coordinated Care (OCC) to oversee behavioral health services and was discussed in our previous report. The OCC continues to be a priority for planning and implementation. While not fully implemented, DPH is hiring OCC staff specifically to support a new Street Crisis Response Team (SCRT).

SCRT launched November 2020 and is in progress of launching a second team February 2021. These teams provide a non-law enforcement response to behavioral health emergencies in public spaces and divert individuals away from emergency rooms and criminal justice settings into behavioral health care. Each team includes a community paramedic, a behavioral health clinician, and behavioral health peer. Each team provides coverage in a specific geographic area with a goal of 24/7 city-wide coverage Spring 2021. In addition to diverting individuals from emergency rooms who may have otherwise been placed on an involuntary psychiatric hold, SCRT will likely be engaging with individuals who have previously been placed on a 5150WIC. Collaboration with the OCC will allow for enhanced data on supporting individuals who are at risk of psychiatric hospitalization.

As discussed, DPH has spoken to one of our largest private hospitals regarding obtaining alerts when individuals with frequent involuntary psychiatric holds are treated at their site. This is in process and will inform future collaborations. We also look forward to seeing State and/or legislative changes as recommended in the original audit to support the sharing of information both within and across counties.

California State Auditor's Assessment of 6-Month Status: Partially Implemented

60-Day Agency Response

Mental Health SF legislation creates an Office of Coordinated Care (OCC) to oversee mental health and substance use services. The OCC is responsible for 1) Maintaining an up-to-date inventory of available space in all City operated and funded mental health and substance use programs; 2) Providing and supervising case managers responsible for monitoring compliance with individual treatment plans and identifying appropriate housing placements; and 3) Coordinating the care of patients who are exiting the County Jail system or General Hospital's Psychiatric Emergency Services. Funding for the OCC has been budgeted pending mayoral approval, and includes a Bed and Patient Tracking System; Jail and PES Linkage Support; Crisis Linkage Support; and more positions for Case Management, Intensive Case Management, and Critical Care Management.

SF-DPH recently reached out to the Manager of Community Health of one of our largest private hospitals asking to discuss the feasibility of obtaining alerts when individuals are admitted for involuntary detention who have had multiple prior involuntary detentions. By working through the details of such a data sharing agreement, we hope to establish a workflow that could be replicated in our other Designated Receiving Facilities.

A Street Crisis Response Team is being developed which will provide a non-law enforcement response to behavioral health emergencies and divert individuals in crisis away from emergency rooms and criminal justice settings into behavioral health treatment facilities. Each team will include a paramedic from the Fire Department, and a behavioral health clinician and behavioral health peer from the Department of Public Health.

California State Auditor's Assessment of 60-Day Status: Pending

All Recommendations in 2019-119

Agency responses received are posted verbatim.