Emergency medical service/original researchImpact of the San Diego Serial Inebriate Program on Use of Emergency Medical Resources
Introduction
Homeless individuals repeatedly intoxicated in public disproportionately consume resources through encounters with police, fire department, emergency medical services (EMS), and emergency department (ED) personnel.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 Traditional chemical dependency treatments have been ineffective for this recidivist population. Intense case management has shown benefit in some2, 5, 10 but not all11 studies, and there is no effective strategy to address their condition. Motivation is essential for recovery, and legal pressure has been capable of motivating beneficial change in behavior for adults with alcohol and other drug problems.14
In January 2000, the San Diego Police Department initiated a pilot Serial Inebriate Program to assist a group of homeless individuals stuck in a “revolving door” between jail, EDs, and the downtown Volunteers of America inebriate reception (sobering) center. Early success allowed this program to evolve throughout the region as a partnership linking law enforcement, fire departments, EMS, hospitals, the public defender, the city attorney, the superior court, Volunteers of America, business, treatment providers, and local government. The goal of the Serial Inebriate Program is to provide patients who have exhausted traditional therapeutic options with a sober living alternative while reducing their adverse community impact. The Serial Inebriate Program aligns the judicial system with treatment to create incentive for individuals’ participation in an outpatient recovery program tailored to their needs.
Law enforcement is responsible for providing individuals determined to be publicly intoxicated with a safe sobering environment. Individuals who lack other means of safe shelter are transported to the inebriate reception center, where they receive supervision and monitoring by treatment staff until sober. Such individuals receive counseling and are encouraged to enter the Volunteers of America recovery program, but many decline this offer and promptly resume drinking. California does consider public intoxication disorderly conduct, and under certain circumstances this misdemeanor can result in incarceration for up to 180 days. The California 4th District Court of Appeals determined that the state may incarcerate intoxicated individuals because it has a legitimate need to control public drunkenness when such behavior creates a safety hazard.15 The court concluded that state law does not punish the mere condition of being a homeless, chronic alcoholic but rather the associated conduct that poses a public safety risk.
California law also provides judges the option of offering such individuals an opportunity to complete an alcoholism treatment program in lieu of custody. Before the implementation of Serial Inebriate Program, local treatment programs were unwilling to accept these clients because of their recidivist behavior, and jails rarely housed them longer than 72 hours. In 1999, the San Diego Police Department recruited a treatment provider to collaborate in the development of a novel pilot program tailored to this population. The San Diego Police Department also secured the support of the city attorney to develop new booking and sentencing procedures. Importantly, the public defender lent its critical support to program development after concluding clients would be afforded valuable new support and care. Volunteers of America staff were asked to define the criteria that should constitute a “chronic inebriate” (and therefore Serial Inebriate Program client), and the superior court endorsed a trial program.
In January 2000, the court began offering eligible individuals the option of a 6-month outpatient treatment program in lieu of custody (Serial Inebriate Program). Serial Inebriate Program police officers assumed responsibility for monitoring client progress while enforcing laws governing violations of probation. This study was designed to evaluate the impact of the Serial Inebriate Program on the use of EMS, ED, and inpatient resources during its first 4 years of operation.
Section snippets
Materials and methods
The city of San Diego is the nation’s seventh largest, with a population of 1.3 million residents. The city encompasses 73 square miles and is home to 12 acute care hospitals. The city is served by 1 paramedic provider (the San Diego Medical Services Enterprise), a public/private partnership between the San Diego Fire-Rescue Department and the Rural/Metro Ambulance Company. Individuals determined to be publicly intoxicated and for whom there are no other means of ensuring safety are transported
Results
From January 2000 to December 2003, 529 individuals were rejected by inebriate reception center staff and categorized “chronic” after being transported to their facility 5 times within 30 days for public intoxication. The majority of the individuals were men (92%), white (75%), and 35 to 50 years of age (69%). Table 1 demonstrates the use of ED, EMS, and inpatient services by this population at the 2 hospitals and the city’s sole paramedic transport agency. Of the 529 individuals, 79 (15%)
Limitations
This study has several limitations. Medical charges were used to reflect the expense of care, but charges and costs are not equivalent. Second, hospital charges are likely underestimated because only 2 of the city’s dozen hospitals participated in the study. However, these 2 hospitals are the primary receiving facilities for neighborhoods with the greatest numbers of police calls related to alcoholism. Third, this study did not address the direct or indirect costs of operating the Serial
Discussion
This study documents the extraordinary consumption of EMS, ED, and inpatient resources by one city’s population of homeless chronic alcoholics. Assuming an average observation period of 4.5 hours (Dunford, unpublished data) these patients consumed nearly 15,000 hours of ED staff time at 2 of San Diego’s major regional hospitals, which equates to a 34% chance that a Serial Inebriate Program client was occupying an ED bed at one of these facilities at any moment during the 4-year study. These
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Supervising editor: Donald M. Yealy, MD
Author contributions: JVD conceived the study, supervised its implementation, and led the writing. EMC assisted with the study and completed the statistical analyses. SPL assisted with the analyses. PJ assisted in the data collection. TCC and GMV assisted with writing. JVD takes responsibility for the paper as a whole.
Funding and support: The authors report this study did not receive any outside funding or support.
Reprints not available from the authors.