San Diego Serial Inebriate Program (SIP)
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The Medical Home for SIP Patients
Since 2004, the primary health care and out-patient psychiatric care for SIP patients is provided at St. Vincent de Paul Village Family Health Center. Their care begins when the San Diego Police Department Officer picks up the SIP client from the Jail after their conditions of release are set by the San Diego Superior Court, and the Officer brings the SIP client to St. Vincent de Paul Village Family Health Center for their medical and psychiatric evaluation prior to checking in to their recovery program. The SIP patients have typically gone through alcohol withdrawal while they were in the San Diego County Jail, and the San Diego County Sheriff's Department Medical Services team has assisted the patient with medical detoxification, as needed. The medical case manager at St. Vincent's arranges for a copy of the SIP patient's medical record at the Jail to be sent ahead of their appointment, so consistency in their care can be enhanced.
Photo of homeless man

In the first visit to St. Vincent's, the SIP patient will see a physician who is both a Family Physician and a Psychiatrist, and their whole person care will be provided not only in one place but "in one white coat." In an approximately 90 minute physician visit, the patient will have a general medical history and physical examination done, an initial psychiatric evaluation, and have appropriate laboratory studies drawn. Then the Clinic's Dispensary will give them a bag containing any medications needed, for both their general medical conditions and psychiatric care, and the SIP patient is then ready to go with the SDPD Officer to his or her treatment program. The patient leaves with follow-up appointments in hand (typically in 2 weeks, or less if clinically indicated), and they are advised that this team of doctors wants to see them often and to assist them in their recovery.

During this first visit, the concept of "Out-Patient Medical Home" is explained to the patient, and he or she is advised that this clinic is now available to him/her on-going, free of charge, for as long as he/she is willing to come, regardless of recovery status. Of course, the patient's recovery is very strongly reinforced at every possible point of discussion, but our experience shows us that it is important for the SIP patient to know that even if they relapse, we want them to return to their "Medical Home" for health care and psychiatric care, and NOT go to hospital Emergency Departments unless there is a true medical emergency.

Approximately 2/3 of SIP patients continue their care with St. Vincent de Paul Village Family Health Center as their out-patient medical home, on-going. Some of the 1/3 who do not return go to other providers of care because they are able to get health care insurance that allows them to go to a broader range of providers and some do not return because their relapse of alcoholism is so severe they get care from no one, until the Emergency Medical Services are called. But for the great majority of SIP patients, St. Vincent de Paul Village Family Health Center serves them as their out-patient medical home.

Expansion of Services to SIP patients and other homeless neighbors with similar conditions - the Federal Health Care for the Homeless New Access Point Grant:

The U.S. Department of Health & Human Services, Health Resources and Services Administration (HRSA) awarded a Section 330(h) Health Care for the Homeless New Access Point Grant to St. Vincent de Paul Village Family Health Center, with implementation of the project expected by January 2, 2009. This grant award focuses on development of a "medical home" for our homeless neighbors who suffer from substance use disorders, and/or mental illness, and who typically have multiple general medical problems as well. Particular outreach will be extended to homeless patients who currently have no medical home, and who often use the City's Emergency Medical Services and/or the hospital emergency departments for non-emergency care. The total award is $647,754.00 over a 2-year, 9 month period, and the clinic will become a Federally Qualified Health Center (FQHC) in this process. The total budget for the St. Vincent de Paul Village Family Health Center for this period is $8,092,508. Of the total cost, 8% is being financed by HRSA, 11% by other federal sources, 12% by state government sources and program income, and the remaining $69% ($5,603,182) by private grants, donations and contributions.

About St. Vincent de Paul Village:
Aerial photo of St. Vincent de Paul Village Health Center

St. Vincent de Paul Village has been serving homeless and impoverished men, women, youth and children in San Diego for more than 55 years. Established in 1950, the agency has evolved from handing out peanut butter sandwiches on the streets of San Diego to an internationally recognized provider of comprehensive services to the homeless, with a residential campus encompassing more than two blocks of downtown San Diego. As San Diego's largest residential homeless services provider, the Village provides 47% of all available beds in the City of San Diego on a nightly basis. More than 850 adults, teens and children reside in the Village's transitional housing each night. Our mission is to help our neighbors in need break the cycle of homelessness and poverty by promoting self-sufficiency through an innovative continuum of care, multi-disciplinary programs and partnerships that come together in the spirit of our CREED (Compassion, Respect, Empathy, Empowerment, Dignity) to teach, learn from and challenge our neighbors and one another. Our comprehensive continuum of services includes transitional housing, meals, children's services, mental health care, a State certified outpatient substance abuse treatment center, a career and education center, case management, and the St. Vincent de Paul Village Family Health Center. This one-stop service delivery model is not offered by any other provider in the region.

Located within the Village campus is the St. Vincent de Paul Village Family Health Center (VFHC), which provides comprehensive health services to homeless, uninsured and medically indigent people throughout San Diego. The VFHC is a state-licensed community clinic offering primary, preventive and specialty health services to the uninsured since 1987. The VFHC's Mobile Health Clinic (MHC) began operations in February 2006. The MHC is a 40-foot-long truck, outfitted to provide health services with two fully equipped medical examination rooms.

Photo of St. Vincent de Paul Village Mobile Health Clinic
The VFHC provides comprehensive care to the homeless with a team of health care providers, including physicians from UCSD School of Medicine. Faculty physicians and resident physicians from the UCSD Departments of Family Medicine, Internal Medicine and Psychiatry have continuity practices at the Village Family Health Center. The VFHC is the out-patient home for the UCSD Combined Family Medicine-Psychiatry Residency Program, whose faculty physicians are Board Certified in and practice both Family Medicine and Psychiatry. They are able to provide the full spectrum of the patients' needs, not only in one place, but "in one white coat." This team of physicians has trained specifically in our homeless clinic, where the overwhelming majority of the patients served are homeless. The scope of this dual-board-certified physician model is not available in service to the homeless community anywhere else in the nation, and these physicians are able to address the full spectrum of medical and psychiatric care needs of the most complex homeless patients, in the flexibility of an outreach setting.

About this Health Care for the Homeless New Access Point:

This New Access Point Grant will enable the Village Family Health Center to expand operating hours of service at the VFHC by three hours each week. Additionally, the MHC will dedicate 12 hours per week specifically targeting medical services to chronically homeless populations. Although the MHC will target the chronically homeless for services, all homeless individuals seeking assistance from the MHC will be eligible for care. The MHC will work closely with the San Diego Police Department's Homeless Outreach Team (HOT), coordinating with them to provide health care services at suitable locations where the homeless gather in the City, through a regular schedule to be determined. As the City's initial point of contact with chronic homeless inebriates living on the streets, the HOT team provides outreach and engagement services throughout the City of San Diego. Each HOT Team is composed of police officers with training and expertise in outreach to the homeless, and for those who are willing, Officers assist them to seek housing linked with appropriate services. Our goal is to serve as the permanent "medical home" for additional chronically homeless persons and other homeless persons, especially those with co-occurring mental health and substance abuse disorders, as our team of physicians is particularly highly qualified to address their unique clinical needs. Particular outreach will be extended to those homeless persons with no medical home, and who frequently utilize Emergency Medical Services and hospital Emergency Departments for non-emergency care.

This HRSA Grant for New Access Point funding will expand the Village's existing comprehensive system of care offered across all of the full lifecycle of those served. This includes the required primary, preventive and supplemental health services, including substance abuse services, mental health, oral health, case management, community health education and outreach, emergency care, referrals for inpatient care, and eligibility assistance services. Services not provided on-site or through the MHC will be provided through established direct contracts, referral relationships, and collaborative linkages. Referral agreements are in place with the Family Health Centers of San Diego for obstetrics and family planning; the nearby Volunteers of America Inebriate Reception Center for detoxification services; UCSD Medical Center for emergency and inpatient services; and with several substance abuse treatment programs for residential recovery services. Additional supportive services are available through the Village including transitional housing, meals, medical and dental care, children's services, mental health and a State certified outpatient substance abuse treatment center, a career and education center, case management, and more.

With this expansion of St. Vincent de Paul Village Family Health Center's existing comprehensive services, we will reach out to those who historically have faced severe challenges in obtaining appropriate health care. While providing their health care, we will also assist them to engage in the additional services that can help them achieve self-sufficiency and end homelessness.

The Medical Profile of SIP Patients

Every human being is a precious and unique person, and that is very true of our SIP patients. That said, a review of over 100 of our SIP medical records show some trends, and they teach us that we need to be prepared for at least the following:

SIP patients are 95% male, and the mean/median/mode age is 50 years (range: 23 - 71 years)

Photo of homeless man Like so many in the homeless community, it seems that more seniors are finding themselves homeless than in decades past. A typical SIP patient has been homeless for 5-to-16 years, and has had as many as 30 intakes per month at the City's Inebriate Reception Center at Volunteers of America.

As a group, SIP patients have multiple, complex, and intertwined health care needs. In particular:

  • 70% abuse other substances in addition to alcohol
  • approximately 90% have additional mental illnesses, beyond that of mixed substance abuse and dependence
  • just over 38% have psychosis
  • approximately 53% were identified as having one or more infectious disease
  • over half are vulnerable to some form of seizure
  • our collective clinical impression is that cognitive impairment is a significant problem for many SIP patients, but it was under-documented in the medical records
  • 70% of SIP patients actually keep their scheduled appointments; 30% cancel or "no-show"
  • All patients are screened for Vitamin B-12 and folate deficiencies (which are treated as indicated), and all patients are given daily oral thiamine for at least one month and a daily general multivitamin on-going
  • All patients are screened for immunization status and updated as indicated (including pneumonia immunization regardless of age)
Some of the common diagnostic categories identified for SIP patients include:

DIAGNOSIS Percentage Raw Score
Alcohol Abuse/Dep.100.00%111
Other Drug Abuse/Dep.70.27%78
Infectious Disease53.15%59
Depression/Anxiety (non-psychotic)51.35%57
Liver Disease48.65%54
Withdrawal seizure/DT42.34%47
Seizure disorder (not just from withdrawal)12.61%14
Cognitive Impairment (under-reported)10.81%12
Heart Disease6.31%7
Diabetes mellitus1.80%2
HIV disease1.80%2

*note: Diagnoses may be underrepresented due to inconsistencies in interviewer data collection (e.g.- some MDs may not chart historical diagnoses). Numbers may also be underrepresented because many patients are poor historians. Some of the common classes of medications prescribed, in addition to the vitamins and immunizations given as noted above, include:

DRUG CLASS Percentage Raw Score
Mood Stabilizers13.51%15
Cardiovas. Med11.71%13
Diabetes Med1.80%2

Each day that the SDPD Officer arrives at our clinic with new SIP patients, we welcome them to the St. Vincent de Paul Village Family Health Center, and with a smile and a greeting, we tell them right at the door that we are so happy that they're here. We explain that this is their new "medical home," if they want it to be, and that this is a new day - they are headed for a wonderful recovery program, and we want to walk with them as their health care providers for as long as they will allow us to. We're in it with them for the long-run, whatever happens.

Very often the SIP patient leaving that first clinic visit is a bit tearful. When asked why, several have remarked that this is the first time they can remember, at least in decades and maybe ever, that they felt welcomed in a health care facility. That's who we are at St. Vincent de Paul Village Family Health Center, and we want it to continue that way for our patients.

For additional information about St. Vincent de Paul Village: