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"There is a very real chance that people will slip through the cracks, even with the best intentions," says Ted Stinson, chairman of the San Francisco Mental Health Board, which advises city officials on caring for the mentally ill.
The remaining third of the MHRF's residents -- those deemed too ill to move to less restrictive settings -- would be shipped to privately run acute-care facilities outside San Francisco. These institutions, known as Crestwood Manors, are run by a Stockton-based company called Crestwood Behavioral Inc., and are located in San Jose, Vallejo, Novato, and Fremont.
To defend the transfer of the MHRF's sickest residents out of San Francisco, Department of Public Health officials cite a 1999 U.S. Supreme Court ruling that mental patients should be able to live in less restrictive, comity-based settings, rather than in locked hospitals, if they are medically able to.
"My sense is that many of the [MHRF] clients -- the ones that didn't have, say, high levels of medical complexity as well -- can benefit from a different model of care," says Marc Trotz, the DPH's director of housing and urban health. He says that although the new board and care MHRF will offer few of the programs and activities of the old facility, it will nonetheless provide a less restrictive setting for 145 people.
It is much harder to put a positive spin on the DPH's decision to transfer 42 MHRF residents to the Crestwoods, because that is literally a step backward for the city. Before the MHRF opened in 1996, San Francisco paid for its acutely mentally ill patients to live in the Crestwoods, just as it will do after the MHRF is reconfigured. The MHRF was created specifically to end out-of-town transfers of the severely mentally ill. San Francisco voters passed a 1987 bond measure, Proposition C, to fund construction of the MHRF as a more therapeutic and humane alternative.
"This long-term facility will permit patients to remain near friends and families ... which will help hasten recovery," wrote then-Mayor Dianne Feinstein in the 1987 voters' handbook.
Mental health experts say the most ill MHRF residents are likely to suffer more if separated from relatives, friends, and local activities. Some patients' family members don't own cars and could visit them in distant facilities only sporadically. San Francisco's Ombudsman Program, a patients' rights advocacy group, received seven calls in a week from MHRF patients alarmed at the prospect of being sent away from the city, says director Benson Nadell. And public hearings on the matter have been packed with patients, their families, and other supporters.
One of those concerned is Arthur, 69, a MHRF resident with bipolar disorder who preferred not to give his last name. He is among those being considered for a transfer to the San Jose Crestwood. Arthur is a poet who writes about ecological themes, adores Golden Gate Park, and occasionally gives local readings. He proudly adds that he once starred in a local dramatic production of The Fantasticks.
"They just don't have anything like that in San Jose," laments Arthur. "And I would have to give up the park, which would doom me."
"It's not so much about leaving the MHRF for Crestwood, it's about leaving San Francisco for San Jose," he explains. "Do you see the difference?"
Unlike the dreary stereotype of a medieval-looking, bars-on-the-windows mental hospital, the MHRF is light and airy. Though it sits next to its parent, General Hospital, on Potrero Avenue, the two facilities couldn't look or feel more different. The older county hospital is Gothic-brick outside and fluorescently lit inside. The MHRF is sleek and modern, with plenty of windows. Inside, it has the feel of a college, accentuated by its two gardens, computer room, gymnasium, and arts and crafts center.
The MHRF boasts a wide range of programs intended to train residents to live independently in the outside world. There are classes in money management and computers, in which residents can get an e-mail account or learn Microsoft Word. Job skills can be acquired by working in the MHRF general store, and residents learn how to buy a Fast Pass and ride the bus. Several drug and alcohol treatment programs are available, ranging from one based on abstinence to one endorsing "harm reduction" -- that is, teaching people to be safe even if they continue to use drugs. There's even something called "leisure counseling."
"Having spare time on your hands with nothing to do with it puts you at risk to spiral down psychologically," explains MHRF nurse Peter Strauss.
The MHRF's rehabilitation model has been successful -- 90 percent of its residents have returned to the community, and the average length of stay has decreased from 18 to six months since the facility opened. The average length of stay at the Crestwoods is longer. (By how much depends on whom you talk to -- MHRF staffers say two years, Crestwood officials say as little as seven months at some facilities.)
But MHRF's state-of-the-art offerings come with a high price tag.
"It's an expensive facility, I won't lie to you," says Jennifer Baity Carlin, a MHRF substance abuse counselor. However, she says the MHRF is cost-effective in the long run as it keeps people out of even more costly emergency rooms.