San Francisco prepares to expand conservatorships for homeless people

A state bill would allow courts to appoint a conservator for a person who is chronically homeless and unable to care for themselves due to mental illness or substance use, based on frequent trips to emergency rooms, stays in jail and 5150s. (GABRIELLE LURIE/SPECIAL TO THE S.F. EXAMINER)

San Francisco is preparing for an expanded use of conservatorships in anticipation of state legislation that would allow The City to increase their use for homeless persons suffering from mental illness or substance use.

The City’s Public Conservator currently has 577 people under mental health conservatorships and receives about 16 referrals monthly of people admitted for psychiatric care through an initial 5150 72-hour emergency hold.

However that number is expected to increase if state Sen. Scott Wiener, D-San Francisco, succeeds in passing Senate Bill 1045, which expands the criteria for placing a person under conservatorship. The bill would allow courts to appoint a conservator for a person who is chronically homeless and unable to care for themselves due to mental illness or substance use, based on their frequent trips to emergency rooms, stays in jail and 5150s.

The Senate Public Safety Committee will hold a hearing on the bill Tuesday.

Meanwhile, the Board of Supervisors Budget and Finance Committee approved legislation Thursday that would have the City Attorney’s Office take a leading role in arguing for conservatorships. The District Attorney’s Office currently handles the cases but would only handle them for those also facing criminal charges if the legislation is approved.

The City Attorney has proposed three new positions to handle the workload beginning January 2019, which would cost $717,874 annually, according to a report from the budget analyst.

Board of Supervisors President London Breed, who introduced the legislation, said that it was important for the City to “expand the capacity for addressing these particular issues” and “make this process efficient.”

Jill Nielsen, who oversees the Public Conservator program under the Human Services Agency, said she had visited Sacramento this week with Mayor Mark Farrell’s staff to support Wiener’s bill.

Nielsen said that the bill would address a trend they are seeing in San Francisco of homeless persons undergoing psychosis as a result of drug use, such as methamphetamine.

“There are other drugs that our homeless individuals out on the streets are actively using and it creates this agitation psychosis that many of us are very familiar with just from walking to BART or wherever we might be going,” Nielsen said.

Conservatorships are currently allowed under the Lanterman-Petris-Short (LPS) Act passed in the 1960s, which allows someone to be held involuntarily and treated in a mental health facility if the person is deemed “gravely disabled,” which means they are unable to provide their own basic needs like food, clothing or shelter.

Nielsen said that conservatees have remained under conservatorship for an average of five years. “Although LPS conservatorships are intended to be short term, the individuals that we are serving do have serious mental illness and it takes time for them to achieve recovery,” Nielsen said.

Nielsen said when someone is referred, they are evaluated and some are placed in locked facilities while others are located in community settings like a residential care facility for elderly or single room occupancy hotels with supportive services. She noted that in some cases medications are provided involuntarily.

Should Wiener’s bill pass, San Francisco would need to approve legislation to adopt the new conservatorship criteria, according to the budget analyst.

The board postponed a vote Tuesday for one week on a resolution introduced by Breed supporting Wiener’s bill.

David Elliott Lewis, who serves on the Mental Health Board and provides Crisis Intervention Training for police officers, spoke against the resolution. “To enact another law that can deprive people of civil rights to address a political need of seeing homeless people on the street is really troubling,” Lewis told the board Tuesday.

He added, “We need housing and treatment and community supports.”

Barbara Garcia, Public Health Department director, said Thursday that the combination of mental illness, addiction and homelessness “really does cause their inability to take care of themselves,” which is why she supports Wiener’s proposal.

Garcia said it would “provide a little bit of respite for these individuals, a little bit of respite for the neighborhood.”

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San Francisco prepares to expand conservatorships for homeless people

Tragic consequences when nursing homes neglect substance abuse

Kenneth “Bubba” Levesque was taking medicine to quell his cravings for heroin when he entered Braemoor Health Center last summer. Massive infections had forced the amputation of his lower left leg, and he needed help learning how to walk again with a prosthetic limb.

Levesque, a teddy bear of a man, seesawed between addiction and recovery many times over the years, and told his family that this was his wake-up call, that he was finally going to “get clean” while in the Brockton nursing home.

But state records show that three days after Levesque was discharged from Braemoor in March, the 43-year-old was dead from an opioid overdose, a grim coda to his seven months at the nursing home.

During those months, according to state reports and Levesque’s family, he received escalating doses of opioid medications and no substance abuse counseling — at the very time he had vowed to banish narcotics from his life.

Even as regulators and health leaders have launched myriad initiatives to combat the opioid crisis in Massachusetts, nursing homes — where potent pain medications are routinely administered — remain distant outposts.

Few nursing homes are prepared to identify and treat residents with a history of substance abuse, and even when they do, services to care for such patients have typically not been a priority, say addiction and long-term care specialists.

The issue became news this summer when Braemoor became one of at least two Massachusetts nursing homes where state inspectors declared patients in “immediate jeopardy” because of serious violations, including lack of substance abuse treatment and staff training.

Braemoor’s parent company — which has faced other concerns about quality of
care — says it has since significantly improved treatment for residents with addictions.

The critical gap in substance abuse care is expected to grow as baby boomers reach an age when they begin entering nursing homes at a hastening rate, specialists said.

“The addiction crisis is going to be in patients in every demographic, and it behooves nursing homes to learn how to take care of [these] patients,” said Dr. Sarah Wakeman, medical director of the substance use disorder initiative at Massachusetts General Hospital.

Physicians need to be more aware of drug addiction in nursing homes, according to Dr. James Gessner, president of the Massachusetts Medical Society. But that may be about to change. Gessner said the society’s panels on opioid therapy and on geriatric care will soon discuss ways to help physicians better address the issue.

“This is not age-dependent, not social- or economic-background dependent, and it certainly has to be an issue when taking care of our elderly patients, especially with the many mediations our elderly patients are on,” Gessner said.

A June report from the federal Office of Inspector General found that millions of older Americans received prescriptions for commonly abused opioids last year through Medicare, the government insurance program for people over 65.

Nearly one-third of beneficiaries getting prescriptions through Medicare received at least one of these drugs. And on average, these patients each had five opioid prescriptions in 2015, the report concluded.

    ‘The addiction crisis is going to be in patients in every demographic, and it behooves nursing homes to learn.’

Nursing home leaders say they are asking state health regulators for guidance on how best to care for the rapidly growing number of patients coming through their doors with drug addictions.

Tara Gregorio, senior vice president at Massachusetts Senior Care Association, the industry trade group, said administrators worry about visitors slipping nursing home patients opioids and other drugs.

“Some have called for limiting visitors and room searches, but it’s unclear if [state Health Department] regulations would allow for that,” Gregorio said. “And there are concerns about discharge to the community, are we doing it in a way that complies with the department’s regulations.

We believe there are discussions that need to happen on a regulatory front.”

The state Health Department said in a statement it is “in the process of finalizing written treatment guidelines to assist nursing homes in caring for those suffering from substance misuse.”

The guidance arrives too late for Levesque’s family, who say they were repeatedly rebuffed when they asked nurses at Braemoor Health Center about the powerful narcotics Levesque was receiving.

“I got into an argument with the lady who discharged him because they were sending him onto the street with nothing. No [addiction] counseling, nothing,” his sister, Robin Levesque, said.

“We begged them for a place for Kenny to go when he was coming home,” Levesque said. “And they said, ‘I don’t know what to tell you. Go to the emergency room.’ ”

Braemore’s parent company declined to answer questions about Levesque’s care.

The other nursing home recently penalized for lacking substance abuse treatment was Parsons Hill Rehabilitation & Health Care Center in Worcester. A patient there overdosed on heroin after injecting the drug directly into a tube that nurses had inserted so an ankle infection could be treated with intravenous antibiotics.

He survived.

A state investigation did not detail how the patient obtained heroin while at the nursing home but found he wanted help with a substance abuse problem and had not received it. The investigators concluded that Parsons Hill failed to develop substance abuse care plans for that patient and eight others who struggled with addictions, including one who also admitted using heroin while at Parsons Hill.

In the wake of the Braemoor and Parsons Hill cases, the state Health Department in May trained its nursing home inspectors about abuse of drugs in nursing homes to help them recognize whether facilities are providing appropriate care to patients with addictions, according to the department.

Synergy Health Centers, the New Jersey company that owns Braemoor and 10 other Massachusetts nursing homes, said in a statement the company instituted procedures to identify and treat substance abuse problems at all its nursing homes.

Those measures include identifying residents at risk of addiction and referring those with a history of substance abuse to treatment.

The company also is educating staff about chronic pain, opioid use, and addiction. Additionally, it is conducting weekly support meetings for residents run by specialists. Finally, Synergy said it enhanced surveillance in outdoor smoking areas.

Parsons Hill said in a statement it enhanced its procedures, including “increased staff education and awareness in the areas of substance abuse disorders, and has contracted with a licensed alcohol and drug counselor to provide on-site support services.”

The statement did not say whether Athena Health Care Systems, the Connecticut company that manages Parsons Hill, has enhanced substance abuse care at its 18 other Massachusetts nursing homes, or those it manages in Connecticut and Rhode Island. Athena declined to answer further questions.

For patients who have already started down the path to substance abuse treatment, finding a spot in a nursing home can prove vexing. Mass. General’s Wakeman said nursing homes sometimes misunderstand federal regulations regarding treatment of patients receiving medicine to block opioid cravings.

That prompts the nursing homes to claim — erroneously — they cannot accept such patients, forcing Wakeman to regularly hunt for nursing homes for patients who need longer-term care, but who also are receiving treatment for substance abuse.

A New York nonprofit, The New Jewish Home, is trying to make it easier for addicts to find care in nursing homes.

Two years ago, it embarked on an experiment involving 120 patients that included Alcoholics Anonymous meetings in the nursing home, talk therapy, and care by specialists who replaced potentially addictive drugs with medications that don’t lead to addiction.

Program workers paid close attention to patients as they were discharged, to ensure they had ample support, including outpatient therapy and home visits.

Executives for the New Jewish Home said they have not yet calculated how much the intensive program costs for each patient, but have committed to continuing it.

In the first two years, the company found that roughly two-thirds of patients who had been addicted to alcohol or drugs reported no relapse one month after discharge.

“If that home visit indicated a relapse, I would do a second home visit with them, to make sure they are getting whatever services they need,” said Sherry Samaroo, coordinator of the geriatric substance abuse recovery program for the nonprofit.

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Tragic consequences when nursing homes neglect substance abuse