he Psychiatric Emergency Services (PES) at the San Francisco General Hospital and Trauma Center (SFGH) provide 24-hour, 7 day a week emergency assessment, stabilization and disposition for some 6,000 acutely ill adult psychiatric patients a year. About 80 % of PES patients are brought in by police, by ambulance, or by their families.
Because of the eruption of their illnesses, they are often a danger to themselves or others or so gravely disabled they can’t take care of themselves. By the time our patients are brought to the hospital, they’re usually very ill, and are often struggling with severe psychosis, complicated by street drugs. Many are homeless and some haven’t eaten or slept for several days and are often very depleted. Some have been such a strain on their families over such a long period of time that they’ve exhausted them and thus lost their last threads of social support. Most are very poor and many are living on the margins of society.
SFGH is a refuge for these patients as it is one of the last hospitals in the city that is willing to care for them. Since 1990, the number of private hospital beds for acute psychiatric patients has declined from 176 to 71, a decrease of 60 percent and there may be further decreases. The major reason for the dramatic decrease in psychiatric beds in the city is the relatively low reimbursement rates that insurance companies, MediCal and MediCare are willing to pay for psychiatric patients compared to medical and surgical patients. As private hospital beds have closed, the City has become increasingly reliant on the 100 psychiatric beds in SFGH, as the focus of acute psychiatric care.
Caring for patients whose mental illness is chronic and persistent is an extraordinary challenge that requires creativity, innovative strategies and a range of skills. Over the past several years, the PES staff have developed a model of care that extends well beyond the customary parameters of psychiatric treatment to one in which the entire person and the quality of his or her life are the center of concern. Of course, when patients are hospitalized, their psychiatric illnesses and medical problems are addressed first. But preparing the way for them after they leave the hospital is just as crucial to their recovery. A team of psychiatrists, psychologists, nurses, occupational therapists, vocational counselors, substance abuse counselors and social workers provides effective, appropriate care tailored to the special needs of individual patients. Case managers coordinate the efforts, ensuring that clients receive housing, financial entitlements, and access to community services. The multidisciplinary approach is not only effective; it’s cost efficient as well.
Paying attention to the quality of our patients’ lives promotes future psychological stability, thereby decreasing the need for repeated hospitalizations. Patients are provided a safe space with staff who can talk to them in a thoughtful and reassuring way. This is critical in making accurate diagnoses. Because many patients have serious physical problems in addition to psychiatric problems, medical care is first provided. We prescribe medications that are often extremely useful. And we give patients a respite from the stresses they experience on the street, which also helps them withdraw from the illegal substances they’ve been taking.
For San Francisco’s diverse population, cultural sensitivity and attention to special needs are key components in providing effective care. Four inpatient units in the SFGH Department of Psychiatry are devoted to the problems of specific groups of patients: Asian/Pacific; African American; Latino and women; and HIV-infected and gay, lesbian and transgendered people. A fifth unit treats people from the San Francisco County Jail.
While many of the staff of these specialized units speak the language of their monolingual patients, these units are also able to deal with the cultural factors that contribute to the way psychiatric illnesses develop or are expressed. For example, someone from Vietnam might experience depression and describe it as a physical symptom, a heaviness of the heart or certain Asian patients seem to be particularly sensitive to certain antipsychotic medications. The staff are experts in the biological, psychological, emotional, social and cultural issues of the populations they serve.
The quality of the department’s services is complemented by the quality of its teaching program and the best psychiatric residents in the country are drawn to this program. The faculty and staff who work in the department are second to none. Whatever the discipline, staff possess deep compassion, psychological intuition, and clinical wisdom. They have a unique capacity to relate to people who have had life-long difficulties in making personal connections and a real sense of caring about people who often have difficulty evoking sympathy in the general public.
