--- title: "Serial Inebriate Program" type: "pdf" year: "2002" canonical: "/projects/1092" --- # THE CITY OF SAN DIEGO IN REPLYING PLEASE GIVE OURREF. NO. April 23, 2002 4970EDMU Herman Goldstein Award Selection Committee Police Executive Research Forum 1120 Connecticut Ave., NW, Suite 930 Washington, DC 20036 Attn: Herman Goldstein Award I am nominating the San Diego Police Department's "Serial Inebriate Program" for the 2002 Herman Goldstein Award for Excellence in Problem-Oriented Policing. During the past 30 years, the City of San Diego has documented a revolving door syndrome with the criminal processing of homeless chronic inebriates. Statistics obtained from County and City homeless agencies indicated there were between 180 and 250 chronic homeless alcoholics during fiscal year 1999. Annually, these individuals cost the City and County about S3,000,000 in police service, EMS service, hospitalization and medical costs with little or no real effort made to get these offenders off the street and into treatment. Project officers assumed the tremendous task of identifying and bringing together all the appropriate stakeholders to effect change. The stakeholders included the Fire Department/Emergency Medical Services (EMS), Police Department, San Diego Sheriff's Department Detention Facilities, Inebriate Reception Center (Detox), the City Attorney's and Public Defender's offices, the San Diego County Superior Court, San Diego County Drug and Alcohol Services, and the residential and business communities. This collaboration created the Serial Inebriate Program and conducted a pilot project. After a two-year evaluation period, this pilot project has been deemed a success. The statistics for the calendar year 2000 indicate the revolving door has slowed down with the number of chronic alcoholics dropping to 144 . The stakeholders have all reported a significant decrease in the amount of time and resources spent dealing with chronic inebriates. Residential and business communities of the Western Division expressed their pleasure with the significant reduction of disorder issues associated with chronic inebriates. Our department has efforts underway to comply with a recent unanimous vote by the City Council to implement the Serial Inebriate Program citywide. Sincerely, D. $P_{\text {dun }}$ David ano Chief o -olice Office of the Chief of Police 1401 Broadway $\cdot$ San Diego, CA 92101-5729 Tel (619) 531-2000 # Table of Contents - [THE CITY OF SAN DIEGO](#the-city-of-san-diego) - [San Diego Police Department Serial Inebriate Program](#san-diego-police-department-serial-inebriate-program) - [PROGRAM SUMMARY](#program-summary) - [THE SERIAL INEBRIATE PROGRAM](#the-serial-inebriate-program) - [PROGRAM](#program) - [THE SERIAL INEBRIATE PROGRAM](#the-serial-inebriate-program) - [SCANNING](#scanning) - [ANALYSIS](#analysis) - [RESPONSE](#response) - [ASSESSMENT](#assessment) # San Diego Police Department Serial Inebriate Program "Expanding the Vision" ![img-0.jpeg](https://popdatasets.blob.core.windows.net/popdatasetmdimgs/02-48/img-0.jpeg) sa, $\mathrm{P} \bullet$ ![img-1.jpeg](https://popdatasets.blob.core.windows.net/popdatasetmdimgs/02-48/img-1.jpeg) Community Partnerships in Problem Solving # PROGRAM SUMMARY # THE SERIAL INEBRIATE PROGRAM SCANNING: In August 1998 through 1999, the San Diego Police Department researched a revolving door syndrome regarding chronic homeless alcoholics going in and out of jail, Detox, and hospital emergency rooms with alarming frequency. Never were these individuals diverted into treatment and the costs associated with letting this syndrome continue unabated were astounding. To break this syndrome and divert individuals into treatment the officers developed the Serial Inebriate Program (SIP.). This program utilized court proceedings to sentence offenders to custody time with the option of treatment in lieu of jail. This problem solving pilot project started in one division and operated for the calendar year 2000. At the end of 2000 the program was evaluated by the City Council. They said the program diverted a significant number of chronic alcohols off the street and into treatment. They voted unanimously to expand the program throughout the entire City. ANALYSIS: To expand the program the pilot was analyzed from January 2000 through July 2001. The revolving door was significantly slowed down, with $58 \%$ of the people arrested in 2000 having no police contacts in 2001. Jail medical issues never materialized, and $46 \%$ of clients diverted into treatment successfully completed 6-month programs. Problems such as coordinating program training, institutionalizing courtroom procedures, and proper case management for individuals electing to enter treatment needed to be solved. New training strategies had to be developed, memorandums of understandings between program partners needed to be written and a decision had to be made who would represent the program in the political circle, which make or break homeless programs. RESPONSE: The program continued to arrest offenders for being drunk in public. They were held in jail until court. If found guilty and sentenced to custody time, an offer of treatment was made. If the offender elected treatment, a court order was prepared releasing them from jail to enter the treatment program. If the offender elected not to go into treatment he or she would stay in jail. The Office of the City Attorney created a new position to process all program arrests. The Police Department assigned one full time officer and a part time sergeant to the program. County Alcohol and Drug Services assigned one full time assessor and two full time case managers to the program. Participants in recovery more than one year began attending public meetings to speak in support of the program. Memorandums of Understandings (MOU'S) were written with many of the twenty-two treatment providers. The Police Department and Office of the City Attorney remained the overall program coordinators. They trained many members of the public, court and police personnel about the program. They attended public meetings, maintained program statistics, and periodically trained the Office of the Public Defender about the program operations. ASSESSMENT: The program is scheduled for city wide expansion in April 2002. One north county city has adopted their own program using S.I.P. as a model. Individuals continue to be diverted off the streets into treatment. Some are giving back to society by living productive, sober lives. Chronic inebriate disorder issues no longer plague several communities in San Diego. In February 2002, the County Board of Supervisors awarded \$400,000 to the S.I.P. treatment component. The community, program partners and the City of San Diego, all claim the program is successful. # PROGRAM # THE SERIAL INEBRIATE PROGRAM ## SCANNING Emergency medical services call them "frequent fliers," the police call them "chronics," the courts call them "serial inebriates." They are constantly drunk, urinate and defecate on themselves, vomit, stumble along sidewalks looking disgusting, shout, rave and fight, rummage in garbage cans, lie down in doorways, pee in the alley, and fall in front of traffic. They go in and out of jail and area hospitals with increasing frequency never being held accountable for their actions. They create frustration and outrage among police, emergency medical services, courts, and the community. The community and the police believed change was necessary. During the past 30 years, the City of San Diego has documented a revolving door syndrome with the criminal processing of chronic inebriates. Each year the serial inebriate costs the community hundreds of thousands of dollars going in and out of jail, Detox and area hospitals. Although treatment was available and offered, rarely did they volunteer for treatment and get diverted off the streets. The Serial Inebriate Program (S.I.P.) is a collaborative effort between the police, courts, and alcohol treatment providers. It originated as a pilot project operating in one of San Diego Police Departments eight divisions for the calendar year 2000. The program held individuals in jail until arraignment and defendant's found guilty of drunk in public were offered non-custodial residential treatment in lieu of custody time. The program's goals were to stop or slow down the revolving door syndrome, identify legal challenges related to charging the chronic inebriate with drunk in public, determine treatment needs, and assess the impact on jail. To assess an offender's willingness to enter treatment, a County funded alcohol treatment assessor goes into jail and interviews the offender. If eligible for treatment, the court releases the offender to a treatment provider. Failure to qualify or refusal to enter into treatment results in the defendant remaining in jail for their sentenced time. At the end of calendar year 2000, stakeholders claimed the pilot program was successful. The San Diego City Council believed it successfully diverted a significant number of long-term chronic inebriates from the streets, Detox, emergency rooms and into treatment. They voted unanimously to continue seeking Local, State, and Federal funding to increase the number of treatment beds and incorporated it as part of the City of San Diego Special Needs to the Homeless Program. With the support of City Council and County Alcohol Services the Serial Inebriate Program is scheduled to expand throughout the entire city by April 1, 2002. To coordinate expansion with all partners a careful analysis of the pilot program was conducted. # ANALYSIS With the goal of creating an institutionalized citywide program the pilot goals and the performance of each partner were analyzed through fiscal year 2001. After this analysis a response was created so a program incorporating the entire City of San Diego could continue. The stakeholders first analyzed the pilot program goals. Was the revolving door syndrome slowed down? Yes. The Police Department booked 144 chronic alcoholics for a total of 278 arrests into jail for year 2000. FiftyEight percent of the people arrested during the year 2000 had no police contacts in 2001. Communities, which for years have had chronic alcoholic problems on their streets, reported they are no longer plagued with these individuals every day. Western Division was the only division in the City with a decline in drunk in public arrests. Were legal challenges a problem to the program? Not yet. With over 400 arrests there have been minimal legal challenges from the Public Defender. However, recently there have been some $8^{\text {th }}$ Amendment challenges claiming the chronic alcoholic is being unjustly discriminated against because of their status as a homeless individual. In addition to the constitutional challenge the Public Defender is questioning whether it is necessary to incarcerate somebody for drunk in public at all for what they believe is a social problem. The question of incarcerating "drunks" has created discussion within the legal and treatment professions. What the program does is use "persuasion," or as some might call it, "coercion" to get a person into treatment. However, one must not put the chronic alcoholic in the same category as a drug user being diverted into Drug Court. The chronic alcoholics this program tries to get into treatment are near death both physically and socially. Many have been self-medicating mental illness with alcohol, living on the streets for more than 10 years, exhausting family ties and are unable to socialize with other people. They average 30 to 40 trips to Detox a year with one individual being admitted to Detox 212 times in one year. They overwhelm local emergency rooms with sometimes daily admits creating a tremendous burden on an already overcrowded emergency room by taking up much needed bed space with the only medical problem being alcohol poisoning. Chronic alcoholics repeatedly refuse all forms of voluntary treatment offered from Detox and treatment outreach teams. Most have not been sober long enough to think rationally or make a competent decision about changing their lives. This program effectively slows down the revolving door long enough to sober the individual up so they can think about the consequences of their drinking to them and the community which they reside. Were there problems with jail processing the chronic alcoholic? No. The chronic inebriate did not create any more or less problems in jail than any other individuals booked into jail. Was the chronic inebriate treatable? Yes. It is very important to recognize that S.I.P. is an intervention program to start the recovery process. Recovery is a process, not an event. Intervention starts with the offender being held in jail long enough to go to court. Offenders were astonished at not being released when they sobered up. In speaking with clients in recovery, this change of being held in custody until court was a significant event in their lives. Some stayed in jail several months before they elected to try treatment. Many credit jail with "saving their lives." Forty six percent of people entering treatment stayed until or after their court ordered end date. Prior to the S.I.P. process many treatment programs wrote this population off as untreatable. This was because the traditional outreach process could not get this population to voluntarily enter a treatment program. The question of what is a success became an important issue. Was it a success to have the client finish a six-month treatment program, to finish the initial 10-Day treatment program, to get the client to say they would go to treatment or to just get the person off the street long enough so the community could get a break from the daily annoyance of the drunk in front of their business or residence? For these answers we asked the treatment community. The treatment community immediately corrected us by saying there is no failure with somebody who elects to enter treatment. They went on to say they believed just getting this population through the 10-Day program was a success. They told us to change our way of thinking from success or failure to completing or not completing a treatment program. This again comes back to the concept of intervention being a process and not an event. Overall the treatment community was very happy with the program and treatment providers increased from 1 to 15 by the end of 2000 and by April 2002 there were about 25 . With all the pilot goals being satisfactorily answered, the community, the police, City officials, and treatment providers believed the program should expand citywide. To develop a fully operational program citywide each partner's performance was analyzed starting with the police. There were minimal problems associated with arrests made during the pilot year and fiscal year 2001. However there were some stumbling blocks, which needed to be identified and corrected. When the pilot program began officers as well as Detox personnel were able to determine who qualifies as a chronic alcoholic. The Office of the City Attorney wanted only trained Detox personnel and not the police to identify who was to be booked into jail as chronic offenders. By California law offenders arrested for drunk in public had to be offered a chance to go to Detox in lieu of jail. Detox personnel were trained to check their intake roster and determine if the offender was a chronic abuser. If so they would prepare a "rejection slip" for the officer who would in turn book the offender into jail for drunk in public. Part of the revolving door syndrome was abuse of the emergency room by the chronic inebriate. Slowing down this syndrome would reduce the amount of times the chronic alcoholic visited the emergency room for alcoholic intoxication. However, if an offender was intoxicated to the point where they could not be booked into jail they had to go to the hospital. Historically the Office of the City Attorney did not issue notify warrants on drunk in public cases. This meant many individuals who should be going to jail and offered treatment would go to the hospital to "sleep off their intoxication only to be released back to the street for the cycle to begin again. Usually the individuals ending up in the emergency rooms were our worst offenders and needed intervention to curb their alcoholism. By mid 2001, the Office of the City Attorney had agreed to issue notify warrants on these individuals. The police assigned one full time patrol officer to transport and locate housing for the offender deemed acceptable for treatment. Case management is not a police responsibility and a county funded case manager was needed to work with the program. The police department was willing to continue providing transport from jail to treatment providers and make periodic visits of clients in treatment. The pilot project proved these two duties to be very therapeutic in the client recovery and all treatment providers recommended it continue. S.I.P. statistics proved a reduction in calls for service on individual inebriates. Even with this positive reduction, some individual officers refused to participate with identifying the chronic inebriate. Instead of taking the offender (sometimes well known) to jail the officer would leave the person in Detox or book into jail without a hold. When it was discovered a S.I.P. candidate was left at Detox instead of jail or booked into jail without a hold, the police officer assigned to the program conducted a follow-up interview with the arresting officer. The arresting officers responses for not participating with the program were: 1. They did not know the program existed. 2. They did not understand how to identify a chronic inebriate. 3. They did not feel the arrest was worthy of any follow-up. 4. They did not want to do any extra work on a drunk. Sometimes officers would find an alternative to a custodial arrest (leave offender sleeping in bushes, tell them to crawl back into canyon areas and stay out of public view etc.) instead of going through the arrest process. These officers raised the following concerns: 1. They did not want to spend their time on drunks. 2. Were concerned about contagious diseases of the offender. 3. Believed jail would reject the offender for medical reasons and they would have to release the offender at the hospital. If this happened the time just spent on the offender was completely wasted. 4. The alternative was easier than a custodial arrest. Because of these problems with officers failing to recognize the program, the education of all sworn personnel on S.I.P. goals and results became a priority. Also the Department needed to support the program internally within the rank and file. As the program developed Detox became very supportive and assisted with the placement of many individuals into treatment program. However, some problems surfaced during the year. 1. Not all Detox personnel knew how to operate the intake computer. This was a common occurrence and several times a chronic alcoholic who should have gone to jail was accepted into Detox. 2. The Detox computer system was down. When any of these problems occurred Detox staff had to rely on their personal knowledge of the offender. Because of this several offenders were accepted into Detox when they should have been booked into jail. The San Diego County Sheriff processed 221 SIP related bookings during the pilot year. Jail overpopulation was never an issue. The Sheriff kept records on costs for calendar year 2000: 1. City of San Diego pre-arraignment costs were $80,594.65. 2. County of San Diego post-arraignment costs were $196,487.24 Medical issues associated with booking the chronic inebriate was a concern. The Sheriff believed serial inebriates could possibly fill up the critical care floor creating an emergency situation in jail and create excessive non-budgeted medical costs. The total medical costs for the calendar year 2000 were: 1. Inmate medical costs including all medications were: $37,232.27. 2. RN hours dedicated to the project: 696 hours at a cost of $15,954.32. Total medical costs were: $53,186.59 Program stakeholders believe these costs are less to the County than the alternative of leaving the system the way it was and letting the revolving door continue. Research revealed one chronic inebriate had a medical bill of $91,000 in 1998 and a UCSD Hospital study stated 15 chronic inebriates cost almost $1.5 million over 18 months. Numbers like these are well known among hospital and County Administrators. To let this situation continue unabated seemed ridiculous. Stakeholders believed the program potentially could save the County a substantial amount of money by diverting individuals off the streets and into treatment. Even if the savings were minimal the County was getting almost 65% of the people arrested assessed for treatment and $45 \%$ of the assessed people were electing to enter treatment (S.I.P. Fiscal Year 2001 statistics). Prior to S.I.P. all of these individuals were refusing voluntary treatment options and choosing to live on the street fully aware they would only go to jail for a couple hours before being released to drink again. The situation was so bad that the San Diego Downtown Partnership in one of their newsletters concerning the chronic alcoholic said, "Their biggest concern is the systems inability to effectively manage the homeless chronic inebriate." The Office of the City Attorney was responsible for prosecuting all cases and assisting us with any legal issues relating to the program. Initial prosecution of cases was not a problem. However, when custody time became more frequent the Public Defender began questioning whether sentencing chronic inebriates to jail time was a violation of their ${ }^{8 \text { th }}$ Amendment right against cruel and unusual punishment. Several cases were brought to trial with motions to dismiss due to $8^{\text {th }}$ Amendment violations. All motions have been denied and the client was eventually sentenced to custody. Currently one case is pending appeal. The paper flow each case created and inadequate support staff caused an excessive workload for the City Attorney. With this increased workload came confusion on how to properly track cases through the court process. Often it would take several days to determine the outcome of individual cases and required clerical staff to hand search their records. While researching this "momentary loss" of records problem it was determined the major cause was the fact that S.I.P. was still not institutionalized within the Office of the City Attorney. Efficiently tracking cases and program institutionalization absolutely had to be established if the program was going to continue. Adequate treatment providers were the bread and butter of the program. Initially they were skeptical of how individuals would respond to treatment but by the end of the year they claimed S.I.P. a success. The program started with only one agency, Mid-Coast Counseling and Recovery, working with us as a provider. Because of the program's initial treatment success providers increased to 12 by the end of calendar year 2000 and currently has 25 providers. The program continues to be successful in locating beds for every offender released from jail and court ordered into treatment. However, MOU's needed to be written to insure bed space for the program. Research revealed that providing treatment is similar to running a private business. The different providers contract with the County to provide services through request for proposals. Being awarded a contract came with MOU's which the provider must agree with in order to continue receiving money. These MOU's contained such things as maintaining a certain success rate, establishing philosophies regarding treatment of clients, and keeping client statistical information available for quarterly inspections by the County. Initially the success rate was an issue because treatment providers were skeptical how the chronic alcoholic would respond to treatment. After several months they began to see some success in treatment and were more willing to take in clients. Program philosophies sometimes clashed with each other. Some programs believed in what is commonly called a "social model" and others believed treatment was a necessary component to recovery. Treatment teaches coping skills to an individual so they learn how to live with their disease and can sometimes be very traumatic to clients. The social model believes it to be confrontational. The social model program does not require clients to attend treatment but provides necessary education and meetings on the disease of alcoholism. In placing a client for treatment the question of "which philosophy will be better for the client" must be decided. Whether it was a social model or treatment model had to be determined while conducting initial client interviews in jail and during the 10-Day Program at Detox. While at 10-Day the needs of the client were discussed at a "round table discussion" by Detox personnel familiar with all County funded programs, the program case manager/assessor, and the program housing coordinator. This round table approach seemed to work well and $46 \%$ of clients successfully completed court ordered treatment. County Alcohol/Drug Services and the County of San Diego considered the treatment of S.I.P. clients such a success that they awarded the program $\$ 400,000$ to be used for treatment of S.I.P. clients. Research revealed the program had become the "talk of the street" among chronic inebriates. By the end of the 2000 almost all the chronic alcoholics on the streets knew about the program. Officers would make a drunk in public arrest and the offender would tell them they would be rejected from Detox for being a chronic! Many offenders would tell police officers and treatment counselors the trouble they were having facing the reality of a sober life! The program was a good fit with the City of San Diego's already established Homeless Outreach Team. S.I.P. supplied a high enforcement posture and arrested offenders for drunk in public. After criminal proceedings the treatment aspect was offered. The Homeless Outreach Team consists of 4 police officers, 4 Psychiatric Emergency Response Technicians, and 1 person familiar with all County funded residential care facilities. They utilized a non-enforcement posture when encountering the S.I.P. population on the street. It was similar to a good guy, bad guy approach in trying to manage a very difficult population. The two programs complimented each other very well. Several times clients told us they voluntarily entered treatment because they were either going to "jail as a chronic" or the Homeless Outreach Team "was constantly asking them to go to treatment." This "fit" was one of the reasons the City of San Diego incorporated S.I.P. into their Special Needs to the Homeless Program. After researching the program through fiscal year 2001, stakeholders developed the following response for a citywide program. # RESPONSE The program "carrot and stick" approach to get individuals into treatment remained the same as the pilot project. The police took offenders arrested for drunk in public to Detox. Detox would identify the offender as a chronic offender (5 or more visits in a month) and give the officer a rejection slip. The offender was booked in jail and held until arraignment. If convicted the defendant had an option of attending a 6-month residential treatment program in lieu of custody. To oversee the entire program the San Diego Police Department assigned one full time police officer as program coordinator. This officer was relieved of field duties to be responsible for coordination of all Department training, organizing monthly steering meetings, identifying program deficiencies, monitoring day-to-day operations, preparing reports, maintaining overall program statistics, coordinating public presentations on the program, providing transportation from jail to treatment, and making periodic visits to clients in treatment. One sergeant who was assigned to a patrol squad volunteered to supervise the police program coordinator. This sergeant was not relieved of field duties and was responsible for making sure all reports were completed on time and assuring compliance with Department Policies and Procedures. The Inebriate Reception Center (Detox) would determine who was a chronic alcoholic and provide officers with formal rejection slips, which were given to jail intake at the time of booking. They also made available their 10-Day treatment program, which many providers believed was an excellent foundation to start recovery. The Office of the City Attorney assigned one attorney to the program, agreed to issue notify warrants, and aggressively prosecuted all cases. To increase communications between the police and program case managers they provided office space for the police officer assigned to the program. The contract to administer the County of San Diego one-time \$400,000 Tobacco Settlement Award was awarded to Mid Coast Counseling and Recovery under the supervision of Alcohol and Drug Services. This money funded one full time treatment counselor to go into jail and assess client's willingness to enter into a treatment program. Two case managers were hired to locate residential treatment programs for all clients, maintain statistical data relating clients in recovery, and inform the police department when a client walked away or completed a treatment program. The remainder of the money was set aside for client services. This ranged from providing a treatment program to insuring the client had appropriate bus passes and clothes. To ensure bed space for clients electing to enter treatment MOU's were written with several treatment providers. For providers where MOU's were not written they were told that "the program" would pay for individuals accepted into their treatment programs. A separate facility was set aside so the program had guaranteed bed space in case emergency placement of a client became necessary. # ASSESSMENT The program results for the calendar year 2001 were: - 573 total arrests - 241 people arrested - $65 \%$ were assessed for treatment (157 of the 241 people arrested) - $45 \%$ were accepted for treatment ( 71 of the 157 people assessed) - $55 \%$ stayed in treatment (39 of the 71 people accepted for treatment) - $45 \%$ did not stay in treatment (32 of the 71 people accepted for treatment) The City Attorney assigning one Deputy to prosecute all S.I.P. cases proved to be very beneficial. The Police Department sharing office space with this Deputy also was beneficial. The two became more of a team instead of two partners always trying to track each other down for information. Statistical information was easier to obtain and it took less clerical assistance to research each case outcome. The Program Assessor discovered their standard assessment survey (Addiction Severity Index Tool) to evaluate a clients willingness to enter a treatment program did not work on the S.I.P. client. The standard survey did not have appropriate questions to ask the S.I.P. clients. Because of this the Assessor had to modify the survey to accommodate the S.I.P. population. This modified version worked well and was accepted by the courts. The only assessment problem was the assessor using his or her own individual treatment philosophy when conducting the survey. The Public Defender did not agree with the program assessor's philosophy of treatment and would rather utilize a social model. This created a situation where some cases were brought to trial instead of being litigated at arraignment. None of the cases have been dismissed because of any motions brought on by the Public Defender. Housing clients was not a problem. The program now has full time case management, which effectively took the police out of finding housing for clients. The police became more of a consultant to the case managers instead of doing the actual work. Treatment providers rose from about 15 in 2000, to about 25 in 2001. The concept of the Police visiting offenders in treatment was well received by the entire treatment community. They liked the idea of the Police staying involved and believed it kept the client focused on recovery. It also gives a provider the ability to have a client arrested at any time for violating any portions of the court order. With the hiring of full time case managers taking effect in April 2002, the Police Department's involvement in housing was only as a consultant. The case managers took over all responsibilities relating to housing. The Police Department will continue to maintain overall program statistics and visit clients in recovery at individual treatment facilities. Project contact person: Sergeant Richard Schnell or Officer John Liening Address: San Diego Police Department Western Division 5215 Gaines St., San Diego, CA. 92110, (619) 692-4853, Email, res@pd.sannet.gov or d91@pd.sannet.gov