[Hpn] Homeless overrun San Francisco General Hospital
Fri, 05 Jul 2002 10:15:10 -0700
Publication date: 07/05/2002
Homeless overrun SFGH
Inpatient wards at San Francisco General Hospital are taking on the pall of
a homeless shelter.
BY MICHAEL STOLL
Of The Examiner Staff
Little-publicized statistics from the Department of Public Health (DPH) show
an alarming trend: On an average night, homeless people too sick to send
back to the streets fill 119 beds -- more than a quarter of all available
That is double the number of homeless inpatients eight years ago, one
indication of how fast the street population is growing -- and getting
Homeless people are crowding out other patients because they stay longer and
have worse health problems. SFGH is bustling with street dwellers
recuperating from psychotic breakdowns, heart attacks, bronchitis and skin
diseases caused by injection drug use.
The hospital is a more welcoming place to visit than most shelters.
"If you're homeless, you can pretty much be housed at (SFGH)," said Brian
Wetzel, an emergency room nurse. "It's a safe place where you're not going
to get beat up, robbed. You'll get cleaned up, get something to eat, free
clothes and a $1,000 medical workup."
But caring for the army of homeless inpatients is straining the entire DPH's
budget and frustrating planners' efforts to find savings at a time of
painful fiscal cutbacks.
Mitchell Katz, director of the DPH, which now has a budget of $1 billion,
has long maintained SFGH is obligated to treat patients regardless of their
ability to pay. Sixty-nine percent of homeless people have no health
insurance, meaning every extended hospital stay racks up thousands of
dollars in unredeemable medical bills SFGH is forced to eat.
The average homeless patient stays at SFGH for 12.7 days, costing an average
of around $9,200, said Anson Moon, a planner for the Community Health
Network. Among all patients, the average stay is nine days, costing about
The hospital is trying to nudge many homeless people out the door in an
effort to contain the millions of dollars it spends on charity care each
year. It is finding social workers for the most frequent, overwhelmingly
homeless users of the hospital, a few of whom have shown up 50 times in a
The health department pays for their residential hotel rooms, finds them
jobs, even takes them on self-esteem-boosting field trips to the zoo --
anything to help them take control of their health.
The lavish social services have generated controversy. Doctors and
public-health planners cannot agree on who should pay the millions of
dollars it costs to get those people off the street.
"The financial burden to provide housing for the sick should not be the
responsibility of the Department of Public Health," said Alan Gelb, chief of
the hospital's emergency room.
"Homeless people have an increased rate of dealing with crime," he said.
"Because it's crime, should the police department be paying for their
housing? There were people a few years ago setting homeless people on fire.
Should the fire department be paying for it?"
Housing the sickest
In the short run, the hospital's prevention strategy is costly. DPH is
already investing $16 million to house the sickest of the sick. Yet the
public-health establishment is growing increasingly convinced that if it can
coax people away from the squalor of the streets -- the violence, the drugs
and the elements -- most of their health problems will disappear.
"All early reports suggest that supportive housing is not very costly, or is
even a cost savings," said Margot Kushel, a UCSF researcher.
In a recent study published in the American Journal of Public Health, Kushel
found that among the homeless, just 8 percent of patients accounted for 55
percent of visits to the emergency room. Helping that small number get their
lives back together would be fiscally prudent, Kushel said.
The health department is paying for patient subsidies at three residential
hotels and one low-maintenance nursing facility. In August, it is opening up
two more hotels.
Marc Trotz, director of the Housing and Urban Health Program, said the
Broderick Street House, a 34-bed former nursing home that reopened in
November, would save The City a net $1 million in its first year. What would
cost Broderick Street patients just $140 a night would cost $731 a night if
homeless were held at the acute-care ward at SFGH, and at least $300 a night
at the Mental Health Rehabilitation Facility -- and that does not include
SFGH doctors keep homeless people longer than other patients because they
know that discharging them to the street will cause them to deteriorate
medically. San Francisco has one of the highest homeless death rates of any
city in the United States. Last year, at least 183 homeless people died
Robert Lull, chief of nuclear medicine at the hospital and president of the
San Francisco Medical Society, feels the effects of the extra expense for
homeless patients in his department's bottom line. He had to lay off three
of the 12 people on his staff this summer.
Yet despite the cost, he said he is cautious about releasing homeless
patients before they are strong enough to survive outdoors. Homeless people
do not have the luxury of resting at home in bed while they recover.
Too little detox
For fiscal conservatives, subsidized housing for the down-and-way-out has
about as much political appeal as free needle exchange. Critics say the
costly program is immoral because it does nothing to discourage drug and
alcohol abuse, which plagues a majority of homeless people.
Public health's response: One step at a time. A housed junkie is less sick
and less expensive to treat than a homeless junkie.
Homeless activists say the pace of reform is not fast enough, and that case
management is useless without outside programs to refer patients.
"The only means we have to deal with these people is emergency services,
which are the most expensive services we can offer, and we're still cutting
mental health and substance abuse programs," said Chance Martin, an
organizer for the Coalition on Homelessness and a member of the Mental
Health Board of San Francisco, referring to the round of deep city budget
cuts that began last month.
Part of the rise in SFGH's homeless population is because of the opening in
1996 of the 140-bed Mental Health Rehabilitation Facility. Patients used to
be housed in other counties at San Francisco's expense. But even excluding
the mentally ill, the hospital's homeless represented 23 percent of
inpatients in the fiscal year ending in 2001, up from 14 percent in 1994.
One valuable lesson gleaned from health department statistics: Many more San
Franciscans are homeless for at least part of the year than City Hall likes
The Mayor's Office on Homelessness one night in October counted 7,305
homeless people living on the street, in the jail, in shelters and in the
hospital -- 36 percent more than it counted the year before. In the time in
between, however, the health department recorded 12,956 homeless inpatients,
outpatients and emergency room visitors.
Those numbers suggest The City is finding many of its homeless only when
they fall to the bottom of the safety net. Health department officials say
that faced with swelling ranks of homeless people, the only effective
strategy is to triage the sickest into lower-cost housing.
"If we hadn't gotten into this in a big way four years ago," Trotz said,
"the overcrowding at (SFGH) would have been worse."
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