Cutting from the bottom - Page 2

Newsom's mental health budget would trigger federal funding loss, reducing treatment to the most severe cases by a third


Citywide, at 982 Mission St., boasts the facilities, network, and location to serve one of San Francisco's most vulnerable populations. The typical Citywide client suffers from schizophrenia, bipolar disorder, borderline personality disorder, or severe depression. They are likely homeless, grappling with substance abuse, and many have posttraumatic stress disorder.

Citywide employees, doctors, and administrators, as well as physicians from outside the clinic, speculate that cutting outpatient mental health services in a city with one of the highest per capita populations of mentally ill homeless people will ultimately cost the city more money than it saves now. Use of expensive city services like psychiatric emergency rooms, jails, police, and ambulance could all rise.

"Frankly, a lot of these budget cuts do not seem to be very well thought out in terms of what the real cost is going to be," Woodard said. "If you look into the not very distant future, you're going to incur costs that are probably much greater than your savings were initially by making the cuts."

Cabaj said that past funding cuts haven't resulted in higher use of psychiatric emergency services because the DPH prioritizes funding for the most severe cases and screens for those who could possibly be moved into cheaper services. Citywide clients are consistently high users of San Francisco General Hospital acute inpatient psychiatric care, at an average cost to the city of $1,200 per patient, per day, if they don't have insurance or Medical benefits.

Many end up in costly in-patient psychiatric care facilities or are arrested and land in the city's Behavioral Health Court, which hears cases in which defendants have been diagnosed with a mental illness that is suspected of being a factor in their crime. More than 70 percent of the Behavioral Health Court's mandated treatment slots are at Citywide.

"We can manage behaviors that get people thrown out of every other clinic in the city," Fariello said. "Where is that capacity going to be picked up? These are not clients who, if they don't get treatment, maybe their doctor will give them some medicine and it'll be OK. These are clients who are going to continue to be high users unless we intervene."

Citywide figures show a 40 percent decrease in violent reoffenses for clients referred to their clinic from the Behavioral Health Court. Nearly three-quarters who were homeless are able to maintain housing, and more than 25 percent of clients who were frequent users of inpatient psychiatric services have stayed out of the hospital.

"Citywide really is one of the best," said Woodard, who works with Citywide's Linkage Team to stabilize patients from SFGH's psychiatric emergency room. "They provide excellent care for these really fragile, very ill patients. I would say of the community programs, they're really at the top of the list."

Fariello estimates having to reduce the 1,035 clients receiving treatment at his clinic by 400 if the cuts are finalized. He may have to scale back some of his clinic's innovative and successful categories of service — such as employment support and dialectical behavioral therapy, a highly specialized form of therapy with proven success in treating borderline personality disorder. Citywide has the largest DBT team in San Francisco.

Citywide administrators are baffled by DPH's decision-making process, given that it serves the city's sickest, poorest, and homeless — characteristics that should have reduced its cuts, according to the department's priorities outlined in its budget reduction proposal.