Estimated s of Chronic Intoxication in Sonoma County: Initial Study for the Serial Inebriate Program Sonoma County Health Care for the Homeless Collaborative Draft: September 16, 2014 Program Contact: George Berland, Executive Officer Sonoma County Task Force for the Homeless Convener: Health Care for the Homeless Collaborative gberland@aol.com (707) 431-7559 1
What we know about the costs of chronic intoxication in Sonoma County Compiled by George Malachowski, Lynn Campanario, Lauri McFadden, Lynea Seiberlich, Debbie Height, and Georgia Berland, with support from all cited sources within the County of Sonoma. This is an evolving document and represents that best available information at this time. Updated September 16, 2014 Introduction High utilization of services by chronically intoxicated individuals is an identified problem throughout the State of California. In mid 2012, at the request of the Transitions in Care Committee of St. Joseph Health System, The Health Care for the Homeless Collaborative in Sonoma County agreed to work on improving and developing alternate services for chronically intoxicated individuals who are appearing in local emergency departments. San Diego County implemented a solution in 2000 that is now considered a best practice nationally, the Serial Inebriate Program (SIP). This document serves as an analysis and proposal to adopt the SIP model to serve Sonoma County s chronically intoxicated community members. This report is a working document. It includes available data, and can be updated as additional data is reported. s and proposed cost savings for the following service providers are included: Sonoma County Sheriff including Santa Rosa, Petaluma, Rohnert Park, Cotati, Windsor and Sonoma Police Departments, American Medical Response (AMR), Sutter Hospital, St. Joseph s Memorial and Petaluma Valley Hospitals, Sutter Medical Center of Santa Rosa, and Drug Abuse Alternatives Center (DAAC). Problem Statement The SIP program in San Diego was initiated by the San Diego Police Department in response to a large amount of time and resources (approximately $20 million per year) being spent on a small number of individuals who were chronically intoxicated. In one study, 15 individuals in one year cost the health care system in San Diego $967,000 because of their chronic intoxication and associated health complications. 1 This same frustration is experienced throughout the State. In response, Sacramento, Santa Clara, San Francisco, Santa Monica, and other cities and counties in the State have implemented or taken the first steps to implement a SIP program in their jurisdiction. In Sonoma County, St. Joseph s Santa Rosa Memorial Hospital has initiated movement to implementing a SIP program locally with the support of each of the community partners referenced in this document. Brief Overview of the Serial Inebriate Program (SIP) SIP utilizes a Problem-Solving Court model (such as Drug Court) to divert chronically intoxicated individuals out of County Jails and Emergency Rooms for the criminal offense of drunk-in-public. The SIP 2
program involves collaboration between the courts, law enforcement, Substance Use Disorders (SUDs) treatment programs, and housing agencies working together to support the path to recovery for individuals who are chronically intoxicated and frequent users of emergency systems. There are variations in how SIP is implemented in different counties, but the main principles remain the same. Law enforcement brings intoxicated individuals to a sobering (detox) center. After a certain number of visits to the sobering center within a defined period of time (in San Diego, this number is 5 visits within a 30 day period 1, in Sacramento this number is 25 visits in 12 months 5 ), the individual will be booked into jail the next time they are picked up by law enforcement for an incident related to intoxication. The individual is then given the choice of going into a treatment program, or serving their time in jail. As with other types of chronic disease, substance use disorders may require repeated interventions. If the individual re-offends, there is no limit to the number of times they will be given this choice. When the individual chooses to enter into treatment, providing permanent housing is the first step. While housed, the individual receives substance abuse treatment for a defined number of days including wraparound services to meet additional psychosocial, medical and mental health needs. This model has a 64% success rate in San Diego, and has dramatically reduced arrests (58% reduction) and use of emergency medical services (54% reduction) for this population in that area 1. Even more dramatically, the number of publically intoxicated individuals referred to the Sacramento Police Department decreased by 90% during the first 6 years of implementation 5. Data Data was collected from the following service points in Sonoma County: Sonoma County Sheriff (including most local police agencies), AMR, Sutter Hospital, St. Joseph s Memorial and Petaluma Valley Hospitals, and DAAC. Each data source provided information on incidents of service to intoxicated individuals (Table 1), delivery of intoxicated individuals to hospitals by AMR (Table 2), and average costs of each service (Table 3). Geographic information was collected for service to intoxicated individuals by the Sonoma County Sheriff s Department and AMR. The geographic locations are mapped based upon census tract for both Sonoma County Sheriff s Department which includes local city police as noted above (Map 1) and AMR (Map 2). Each map includes the service locations for each hospital and the detox center. The new Sutter location is indicated along with the current Sutter location, to see how the new location is oriented with the current pick-up locations. 3
Table 1. Incidents of Intoxication November 1, 2012 to May 1, 2013 Intoxicated Unique Individuals Chronically Intoxicated SoCo Jail- 647(f)* charges 1,208 639 197 647(f)who accessed DAAC Outpatient, Detox, and/or Residential services 3 n/a n/a 28 Chronic Definition 2 or more arrests 4 or more arrests DAAC- Detox 543 n/a n/a n/a Sutter- Diagnosis of ER Patients 268 n/a n/a n/a AMR- Toxicological Report 698 n/a n/a n/a * Penal code 647(f) refers to the Drunk in Public or Public Intoxication law enforced when a person is unable to exercise care for their own safety or the safety of others OR are obstructing, or preventing others from using streets, sidewalks or other public ways. Table 2. AMR Incidents of Intoxication and Hospital Deliveries 11/1/2012 to 5/1/2013 Intoxicated % of Total AMR- Toxicological Report 698 n/a Kaiser Hospital Santa Rosa 90 13% St. Joseph Petaluma Valley Hospital 21 3% St. Joseph Santa Rosa Memorial 349 50% Sutter Medical Center of Santa Rosa 179 26% None 42 6% Table 3. Inebriate Incident Scenarios and Estimated s from 11/1/2012 to 5/1/2013 s Used in Estimates Law Enforcement (2 Hours of Officer time) $176 Jail Booking Fee $164 Daily Incarceration Rate $135 Range of Avg. Inebriant for an ER Visit* $4,379-4,709 Range of Avg. Inebriant Cos for Inpatient Visit* $16,549-25,066 Average AMR Ambulance Trip $2,300 DAAC Detox Daily Rate $117 DAAC 31 Day Residential Treatment (daily bed rate $76) $2,357 *Range based on a survey of local hospital costs from Nov. 1, 2012-May 1, 2013. 4
Map 1. 5
Map 2. 6
Data that is still to be collected and added is the cost of a day in Jail, an average number of days in jail for this population, and the cost of local Court processes. Data analysis It is important to note that the data provided by each service location may include duplicate intoxicated individuals. The data did not allow analysis to determine how many unduplicated individuals were served at each location, or how many service locations each individual utilized. The data does reflect, however, an estimated total cost to the system by this population. It provides a clearer picture of where cost savings may be experienced if the SIP program is implemented. Firstly, treatment services cost less than the other services. A typical stay in Detox is three to five days, the total cost equaling $351-$585. The lower end of this range is approximately the same cost of law enforcement picking up an individual and booking him into jail ($340). This law enforcement and booking cost does not include the cost of time spent in jail or additional court fees, suggesting that Detox itself is a less expensive service. Individuals accessing DAAC s Detox are assessed and referred to enter other levels of SUDs treatment, such as 31 days residential treatment, intensive or standard outpatient treatment (for a minimum of three (3) months) and/or Medication Assisted Therapy (MAT), such as with methadone or buprenorphine. As an example, a 31-day residential stay can be accessed for the same cost as one AMR transport, and is half the cost of one ER visit. Several scenarios are presented below to reflect current costs and potential savings (Table 4). These scenarios do not reflect the entirety of services to this population. 7
Table 4. Scenario 1: Law Enforcement to DAAC Detox Law Enforcement $176 DAAC Detox Daily Rate $117 Total $293 Scenario 2: Law Enforcement to Jail Law Enforcement $176 Jail Booking Fee $164 Day of Incarceration 135 Total $475 Scenario 3: Law Enforcement Calls Ambulance Goes to ER Law Enforcement $176 AMR Ambulance Trip $2,300 ER Visit $4,379 Total $6,855 Scenario 4: Health Care Clinic Calls Ambulance Goes to ER Released to DAAC Detox AMR Ambulance Trip $2,300 ER Visit $4,379 DAAC Detox Daily Rate $117 Total $6,796 Scenario 5: Law Enforcement Calls Ambulance Goes to ER Admitted to Hospital Law Enforcement $176 AMR Ambulance Trip $2,300 ER Visit $4,379 IP Visit $25,066 Total $31,921 As shown in these scenarios, there are clear cost savings to both Sutter and St. Joseph s Hospitals when patients can be diverted directly to detox instead of to the ER by either the police officers or the EMS. Actual cost savings have been shown in these same areas by both the program in Sacramento and in San Diego. In Sacramento, the total cost of jail, inpatient detox, emergency department visits, and hospitalization averaged $68,760 per person. After six months in SIP program, this amount was reduced 8
to $18,700 per person 5. Similarly in San Diego, the cost to emergency medical services (EMS), emergency departments (ED), and inpatient departments was reduced by 50% when an individual participated in the SIP program. This equaled savings of $5,662 (EMS), $12,006 (ED) and $55,684 (inpatient) per person 4. Capacity of DAAC s current treatment services has been assessed. The Turning Point Orenda Detox program (Detox) in Santa Rosa, run by DAAC, is currently funded for half of the beds that are available (15 beds), so with additional funding, they can serve up to twice as many individuals in detox (30 beds total). The number of AMR transports to various hospitals is approximately the same number as Detox is currently serving, so diverting these individuals to Detox instead of the ER may bring the Detox to its full capacity. Similarly, the number of arrests by the Sheriff s Department and local police included in the Sheriff s report is approximately the same number that the Detox is currently servicing. Map 1 and Map 2 suggest that the Sheriff s and Police Departments and AMR are serving different populations, which points to a potential need to expand the detox capacity further, particularly in other areas of the county, such as in Petaluma or West County. Discussion Some of the components of SIP have already been put in place here in Sonoma County. DAAC has reinitiated a Sobering Center, and operates Social Model Residential Detox, and additional Inpatient and Outpatient treatment programs that can be used within this program model. There are additional residential and outpatient treatment facilities in the county, such as California Human Development Corp., Santa Rosa Treatment Program, and Women s Recovery Services, which offer additional capacity. The Santa Rosa Police Department and other law enforcement agencies are able to, and have been, transporting community members to the Sobering Center as appropriate, which is an open door to the additional treatment services. Best practice for treatment of alcohol abuse does not define a set length or modality of treatment; rather, a combination of residential treatment (minimum 28 days), followed by outpatient treatment (3-6 months), and ongoing after care, or chronic care management, are recommended according to the problems, needs and progress of the individual. Recovery from alcohol (and other drug) addiction is a long-term process and frequently requires multiple episodes of treatment 6. In Sonoma County, capacity would need to be assessed, as well as available funding sources (which often dictate length and availability of treatment services). Furthermore, effective treatment responds to multiple needs of the individual, such as housing (addressed in this paper) as well as other poly drug use, and associated medical, psychological, social, vocational and legal issues. Linkages to our primary and behavioral health systems of care would be paramount to participant success. As stated earlier in this document, model SIP programs contain the following three components: Court, Treatment, and Housing. Direct access to treatment alone accounts for cost savings indicated in this report; however the success of the SIP program includes all three components. The two components that are yet to be established are Court involvement and Permanent Housing. The relationship between court sentencing and program success was studied in San Diego. In a 4 year study 9
of San Diego s program, 63% of individuals with jail sentences longer than 150 days opted for treatment, while only 20% opted for treatment if they had between 0-30 day jail sentences. There was a 50% reduction in use of EMS and ED services associated with acceptance of treatment 4. Sacramento s program includes 90 days of court-ordered treatment, and the arrest rate for being drunk in public dropped by 94.2% for graduates of the program 5. Court initiated treatment has worked to break the cycle of public intoxication when the SIP model is in place. Data on the specific effect of housing on program success is not included in the studies referenced in this document. However, both San Diego and Sacramento SIP programs use the housing first model, where the participant is housed in permanent supportive housing at the start of the program 4,5. In each case, housing is recognized as a basic part of the program. In Sonoma County, housing for people at all income levels is in short supply and what may become available is expensive. The Sonoma County Continuum of Care estimates a current need for 1600 Permanent Supportive housing units countywide for the general population, which highlights a shortage for the population addressed in this paper. Additional steps need to be taken within Sonoma County to include the Community Development Commission, the Continuum of Care, local housing authorities and housing managers in the development of a local SIP program, and to create new Permanent Supportive Housing units in order to fully support our community members to a successful recovery. There are additional anticipated natural consequences of implementing SIP in Sonoma County that are not presently included in this data analysis. This includes time saved by emergency medical responders. Contracted ambulance providers have response time obligations and can incur fines if they are not met. When Emergency Rooms are impacted and the wait time is increased for ambulance off-loading purposes, the system is depleted which results in longer response times to patients in need of emergency assistance and potentially increased response time penalties. The implementation of SIP can reduce and possibly eliminate these wait times for transport of chronically intoxicated community members. A second natural consequence will be an improvement to the general wellbeing of our community. In Sacramento, SIP has reduced the burden on local businesses who frequently contacted the police to help remove intoxicated individuals from their area, and it supports the overall improvement of health of the participants in a way that other organized efforts to address chronic intoxication have not succeeded 5. The city of Petaluma has been working on implementing parts of the SIP program determining a need for a local response in that part of the County where transportation to Santa Rosa may be prohibitive. Other service areas may be doing the same. The intention is to have one countywide collaborative program with service elements possibly existing in more than one community. Additional communication with relevant parties will be helpful to continue to improve collaboration across the County. 10
Resources 1. (2008, July). Problem Solving with SDPD s Serial Inebriate Program. The Informant. The Official Publication of the San Diego Police Officers Association. XXVIII, 5. Retrieved April 17, 2014, from http://www.sandiego.gov/sip/pdf/sdpd%20pages.pdf 2. (2012, November 20). Accept report from Public Health Department relating to providing business case, outline of Sobering Center and operations, site location, financing and operational logistics; recommendation to fund Project Manager from EMS Trust Funds; and, issuance of Request for Information (RFI) on November 21, 2012. The County of Santa Clara California. Report 64677. Retrieved on April 17, 2014, from http://sccgov.iqm2.com/citizens/detail_legifile.aspx?id=64677 3. (2012) Substance Abuse Treatment (at the Drug Abuse Alternatives Center) for those arrested four (4) or more times for an on-view charge of 647(f)PC and booked into Sonoma County Jail in 2012. Arrest data retrieved by Chief Jeffrey Weaver, Sebastopol Police Department in September 2013. 4. Dunford JV, Castillo EM, Chan TC, et al. (2006, April). Impact of San Diego Serial Inebriate Program on Use of Emergency Medical Resources. Annals of Emergency Medicine. 47(4), 328-336. Retrieved April 17, 2014, from http://www.sandiego.gov/sip/pdf/impact%20of%20san%20diego%20sip%20on%20emergency%20med ical%20resources.pdf 5. Sutter Medical Center, Sacramento. (2012). Serial Inebriate Program 2012 Statement of Impact. Retrieved on May 9, 2014, from http://www.sacselfhelp.org/images/sip-sutter_acr_2.pdf 6. National Institute on Drug Abuse (2009, September). Drug Facts: Treatment Approaches for Drug Addiction. Retrieved on May 16, 2014 from http://www.drugabuse.gov/publications/drugfacts/treatment-approaches-drug-addiction 11