San Diego Serial Inebriate Program (SIP)
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San Diego Serial Inebriate Program (SIP) Photo of James V. Dunford

James V. Dunford, MD, FACEP
City of San Diego Medical Director (EMS)
Professor of Clinical Medicine and Surgery
Department of Emergency Medicine
UCSD Medical Center

Background
I am proud that San Diego has taken a lead role in addressing one of the nation's most frustrating public health concerns, i.e., the management of chronic homeless inebriates. These individuals are stuck in an endlessly revolving door between jail, detox and emergency departments (ED's). Since I began my career in emergency medicine in 1980, I have felt frustrated and powerless to treat these patients. With the genesis of SIP in 2000, I learned my sense of exasperation was shared by every San Diegan who interacted with this population. From law enforcement and treatment providers to public defenders and the business community, no one had answers for this group of people who consumed vast resources without demonstrable benefit. I was discouraged by my inability to do anything more than order an infinite number of CT scans, repair countless scalp wounds and process these people back to the streets, knowing they would soon be transported back in the same or worse condition.

In 1997, I could hardly believe my ears when 2 San Diego police officers mentioned their department wanted to take a fresh look at the problem. The leadership of the San Diego Police Department understood the value of "problem-based policing". Knowing money talked louder than empathic pleas, I did a quick study of the medical costs incurred by 15 individuals over 18 months (July 1997 - December 1998) at 2 area hospitals. To the amazement of many (but not me), these individuals accrued 417 ED visits and their bills for EMS and hospital care totaled nearly $ 1.5 million. The study dramatically demonstrated to civic leaders the scope of the problem and helped to galvanize action. Once resources began flowing for additional officers, SIP was born. Today, SIP is a great example how effective a team of stakeholders can be in addressing a problem none could solve on their own.

Importantly, SIP is coordinated by the San Diego Police Department, which serves as the arbiter and voice of the program. It takes special officers to assume such roles. San Diego is fortunate to have 2 such individuals in Sergeant Richard Schnell and Officer John Liening. What I find remarkable is that SIP has demonstrated the therapeutic value of law enforcement in a particular disease state. SIP effectively treats a medical condition that has defied every other scientific approach. By employing compassionate "tough love" with the assistance of a police officer, SIP provides unique leverage to maintain clients' desire to remain sober and continue treatment. In the scope of my duties at UCSD, I also care for many of the SIP clients in the County Jail. I have never met someone who didn't appreciate the fact that SIP forced them to slow their drinking and have time to reflect. One SIP client once told me, "SIP is the best worst thing that ever happened to me."

The other SIP team members include representatives of the County Sheriff, Superior Court, Public Defender, City Attorney, Volunteers of America (VOA) Sobering and Detoxification Center, Mental Health Systems, Inc. (a treatment provider and case manager), St. Vincent de Paul Medical Clinic (the new "medical home" of clients) and the San Diego Medical Services (the City 9-1-1 provider). The two hospitals closest to downtown, UCSD Medical Center and Scripps-Mercy Hospital, are active SIP supporters.

SIP Operation
It is important to realize that neither hospital personnel, police officers nor treatment providers "place" people in SIP. SIP is a process that begins when recidivist public intoxication results in a judge's determination that incarceration or mandatory treatment is warranted. SIP employs "coerced rehabilitation", i.e., individuals must choose incarceration or treatment in lieu of incarceration. Public intoxication is a misdemeanor in California - see Penal Code 647(f). Publicly intoxicated individuals transported by police to the VOA sobering center 5 times within 30 days are refused entrance, designated "chronic" and brought to jail where they are held until trial. If found guilty, judges may offer a mandatory 6-month treatment program in lieu of custody or progressive sentences of up to 180 days. If patients accept treatment (and 60% do once their sentences reach 120 days), they are transported by the SIP police officer to St. Vincent de Paul (SVDP) Village Family Health Center. They are evaluated by UCSD Combined Family Medicine-Psychiatry resident physicians and faculty and informed that SVDP is their new "medical home", replacing the EDs.

Results
Since 2000, over 900 individuals have met the definition of "chronic" and qualified for SIP. Initially, most individuals decline the SIP treatment option when it is offered as an alternative to 30 days in custody; they come to accept treatment when facing progressively longer sentences and often do well. There is also a significant reduction in EMS and hospital charges incurred by the group accepting treatment. In 2006, my colleagues and I verified the value of the program. Subsequently, this work was recognized by Philip Mangano, Executive Director of the U.S. Interagency Council on Homelessness with the 2007 Pursuit of Solutions Research Award.

Dunford JV, Castillo E, Lindsay S, Jenson P, Vilke G, Chan TC. Impact of the San Diego Serial Inebriate Program (SIP) on use of emergency medical resources. Ann Emerg Med. 2006;47(4):328-336. This is the abstract of that study.

STUDY OBJECTIVE: We determine the impact of a treatment strategy called the San Diego Serial Inebriate Program on the use of emergency medical services (EMS) and emergency department (ED) and inpatient services by individuals repeatedly arrested for public intoxication. METHODS: This was a retrospective review of health care utilization records (EMS, ED, and inpatient) of 529 individuals from 2000 to 2003. Judges offered individuals a 6-month outpatient treatment program in lieu of custody (Serial Inebriate Program). Demographics and health care utilization are reported overall and by treatment acceptance. RESULTS: From 2000 to 2003, 308 of 529 (58%) individuals were transported by EMS 2,335 times; 409 of 529 (77%) individuals amassed 3,318 ED visits, and 217 of 529 (41%) individuals required 652 admissions, resulting in 3,361 inpatient days. Health care charges totaled $17.7 million (EMS, $1.3 million; ED, $2.5 million; and inpatient, $13.9 million). Treatment was offered to 268 individuals, and 156 (58%) accepted. Use of EMS, ED, and inpatient services declined by 50% for clients who chose treatment, resulting in an estimated decrease in total monthly average charges of $5,662 (EMS), $12,006 (ED), and $55,684 (inpatient). There was no change in use of services for individuals who refused treatment. There was a significant increasing trend in acceptance among individuals with longer jail sentences (<0.001). Treatment acceptance was 20% among those with sentences of 0 to 30 days and reached 63% for those with sentences longer than 150 days. Operational costs and alternate care at clinics and nonparticipating hospitals were not analyzed. CONCLUSION: This community-supported treatment strategy reduced the use of EMS, ED, and inpatient resources by individuals repeatedly intoxicated in public.

Current SIP Challenges
Despite the program's success, there obstacles remain to ensure that all individuals who might benefit from SIP are included. For example, only ambulatory intoxicated patients may be accepted by the VOA Sobering Center, which utilizes a "social model" program and has no medical personnel. Consequently, grossly intoxicated patients are transported by paramedics to EDs and may never accumulate the 5 VOA visits required to be designated "chronic." In addition, patient confidentiality issues must be observed. It is not a crime to be drunk in an ED nor is public intoxication a reportable public health condition like tuberculosis or STD. Thus, there is no means currently for ambulance and hospital staff to refer clients they believe would benefit from the program. Finally, police shortages can mean that such low-priority calls do not always receive officers at scene prior to medic transport. In these situations there are no records of PC 647(f) infractions for judges to gauge an individual's recidivism.

Future
Serial inebriates are only one among numerous populations that overuse public safety, EMS and emergency resources. Recently, San Diego EMS has initiated a Resource Access Program (RAP) to address these concerns. Utilizing a paramedic working closely with the San Diego Police Department's Homeless Outreach Team (HOT) and SIP officer, more effective case management is expected. The RAP Coordinator will serve as a resource for EMS and hospital personnel, working with me in my role as City Medical Director, to better match the resources and needs of these individuals.

Read more information about the City of San Diego's Emergency Medical Services.