Sobering Centers Explained: An Environmental Scan in California SEPTEMBER 2021 AUTHOR Shannon Smith-Bernardin, PhD, RN Contents About the Author 3Introduction This report was prepared by Shannon Smith- Bernardin, PhD, RN, of Smith-Bernardin 3Background Consulting. She is assistant professor at the University of California, San Francisco School 5Approach of Nursing, and president and cofounder of 5Findings the National Sobering Collaborative. 13 Challenges Acknowledgments The author would like to thank the interview 16 Effect of the COVID-19 Pandemic on participants, staff of the sobering centers Sobering Centers throughout California, and the champions nationwide who strive to provide safe, com- 17 Further Developing the Role of Sobering passionate, and comprehensive care to our Centers Throughout California neighbors with the most complex health and social services needs. Your work is critical to 18 Recommendations to Promote Adoption of both those you serve and your communi- Sobering Care Model in California ties. The author also thanks the University of California, San Francisco School of Nursing 21 Recommended Collaborations/Colocations for Intramural Fund and the California Health Sobering Centers Care Foundation for funding this project. 24 Conclusion About the Foundation 25 Appendix. Sobering Center Profiles The California Health Care Foundation is dedicated to advancing meaningful, measur- 35 Endnotes able improvements in the way the health care delivery system provides care to the people of California, particularly those with low incomes and those whose needs are not well served by the status quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford. CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemakers to create a more responsive, patient-centered health care system. DESIGN BY DANA KAY HERRICK Introduction S obering centers offer an alternative to the did not advance. They include AB 1795 (Gipson and emergency department (ED) and jail for people Ting, 2018, "Emergency Medical Services: Behavioral who are acutely intoxicated in public. A person Health Facilities and Sobering Centers"); SB 944 with acute intoxication in public can suffer numerous (Hertzberg, 2018, "Community Paramedicine Act of harms, including injury from falls, poisoning, exposure 2018"), and AB 3115 (Gipson, Bonta, Hertzberg, 2018, to the elements, or victimization. Typically, the intoxi- "Community Paramedicine or Triage to Alternate cated person is brought either to jail or the ED until Destination Act"). they have sobered sufficiently to no longer be a dan- ger to themselves. Most recently, California legislators passed AB 1544 (Gipson and Gloria), the Community Paramedicine or Informed by interviews with leaders in the field and Triage to Alternate Destination Act, which was subse- stakeholders, this report describes the range of quently signed into law on September 25, 2020.4 This sobering center models in California and documents bill allows for the expansion of local emergency ser- commonalities, differences, collective challenges, and vice agencies to establish alternative destinations for best practices. This report is intended to provide back- triage and transport by paramedics. Sobering centers ground for health care leaders and policymakers in are included as a potential alternative destination for California when planning for, developing, and enhanc- the care of acute intoxication. ing the use of sobering centers for acute intoxication. History of Sobering Centers Sobering centers, also referred to as stabilization or Background recovery programs, diversion centers, or sobering One-quarter of the nation's known sobering centers stations, were initially piloted in the United States are in California. Multiple centers have been devel- 50 years ago. Originating with the inception of the oped in the last five years with support from California's Uniform Alcoholism and Intoxication Treatment Act of Whole Person Care Pilot,1 made available through the 1971, community-based strategies were developed state's Section 1115 Medicaid Waiver, and Proposition to provide supportive care sites for adults acutely 47 grants.2 As programs have developed in California, intoxicated on alcohol.5 This act was designed to pro- there has been considerable discussion regarding the vide states with the legal framework within which to use of sobering centers as an alternative destination to approach care for alcoholism and public intoxication the emergency department for ambulance personnel. from a health standpoint. California Emergency Medical Services Authority has an ongoing pilot evaluating ambulance transports to Before sobering centers were established, the tradi- alternate destinations, including sobering centers and tional response to public intoxication was detainment mental health facilities.3 Three sobering centers partic- of intoxicated people in jail cells specifically desig- ipate - the San Francisco Sobering Center, the David nated for this purpose - colloquially referred to as L. Murphy Sobering Center in Los Angeles, and the "drunk tanks." As an alternative to this approach, Mission Street Sobering Center in Santa Clara County. which was generating increasingly negative outcomes including deaths from underlying injuries, illness, There has likewise been ongoing legislative action, or suicide, sobering facilities arose with the primary including four bills proposed since 2018, aiming to purpose of monitoring, stabilizing, and coordinat- update statewide emergency medical services (EMS) ing provision of care for clients acutely intoxicated policy to permit ambulance transport directly to des- on alcohol. These original programs from the early tinations other than the ED. Three of the four bills 1970s initially intended to support people during Sobering Centers Explained: An Environmental Scan in California www.chcf.org 3 acute intoxication ("sobering") and then throughout effects resulting from acute drug intoxication, includ- the alcohol withdrawal and early treatment ("detoxi- ing risk to the user and to those around them, varies fication") phases. The target population was primarily based on the specific drugs consumed. Examples those with chronic public intoxication, many without include respiratory depression or death from opioid homes and with frequent contact with the criminal jus- overdose or the co-ingestion of opioids, alcohol, or tice system. benzodiazepines; unintentional ingestion of fentanyl; or behavioral manifestations of psychosis or hallucina- tions from methamphetamines or phencyclidine (PCP). The Need for Sobering Services Alcohol use disorder is the most prevalent substance use disorder in California6 and in the country,7 and Sobering Centers Today accounted for more nonfatal emergency department The primary purpose of a sobering center today is the visits in California than all other drug diagnoses com- short-term (< 24 hours) sobering of adults with acute bined.8 Acute alcohol intoxication may be classified as intoxication who don't need hospital-based care.13 complicated or uncomplicated. Cases are classified as There are an estimated 40 sobering centers in the US, complicated acute alcohol intoxication if they result with dozens more in development, offering around- from direct deleterious effects of heavy or long-term the-clock services. Sobering centers offer a safe place drinking (e.g., respiratory depression requiring intu- for patients to wait for the effects of alcohol or drug bation, liver failure) or by other conditions masked intoxication to wane while being monitored for under- by acute intoxication (e.g., intracranial hemorrhage, lying medical conditions or injury and then connected hypo or hyperglycemia, or cardiac events), all of which to treatment and services. Typically, sobering centers would necessitate ED care.9 provide screening for substance use disorders, brief interventions including motivational interviewing, and Uncomplicated alcohol intoxication does not require direct referrals and transfer to substance use treat- ED-level care. When a person with uncomplicated ment, shelter, or other stabilizing services. alcohol intoxication is brought to the ED, care is gen- erally supportive (i.e., requiring observation only). Many sobering programs focus on relieving both the These patients are typically not admitted to the hos- criminal justice system and the emergency medical pital. Moreover, a prolonged ED stay can lead to system by diverting intoxicated adults from jail and alcohol withdrawal, a potentially dangerous condition emergency departments, respectively. Depending on resulting from sudden cessation of alcohol intake and factors including staffing, funding source, state or local manifested by seizures, severe hyperthermia, uncon- laws, and organizational mission, sobering centers may sciousness, or even death.10 Studies have shown accept intoxicated people referred by ambulances, law that for patients assessed with uncomplicated alco- enforcement, emergency departments, clinics, other hol intoxication in the emergency department, less community programs, or via self-referral.14 In response than 1% required medical care during their stay.11 It to the changing drug use trends across the US, some is possible to screen for uncomplicated acute alco- programs have developed flexible approaches that hol intoxication in out-of-hospital settings (e.g., via incorporate the ability to stabilize adults intoxicated ambulance triage) using indicators such as vital signs, on other drugs (such as opioids, methamphetamines, glucose levels, and the absence of evidence of injury.12 or crack cocaine) in addition to or distinct from alco- hol. Although supportive services and referral capacity Drug intoxication can likewise impair individuals may be available on-site, the sobering care model is resulting in a need for evaluation and oversight. Many not intended to be a treatment facility nor provide sobering centers accommodate individuals acutely rehabilitation for substance use disorders. intoxicated from drugs, in addition to alcohol. Harmful California Health Care Foundation www.chcf.org 4 Distinguishing Sobering Care from Approach Other Services The key question for this project was, What role do Two other substance use–related interventions are sobering centers in California play in the care of those often confused with the sobering care model. First is with acute alcohol and drug intoxication? This report is detoxification, typically referred to as medical or social based on three primary sources. First, semi-structured detox.15 The goal of detoxification is to safely facilitate interviews were conducted with two dozen key stake- complete cessation of alcohol intake often by slowly holders involved in the design, implementation, and/ reducing the amount ingested over a period of days. or operation of sobering centers throughout California. This can be done with or without medication assis- Second, programmatic documents and related files of tance, depending on the patient and in consultation these centers were reviewed to infer common prac- with a medical provider. Medication is offered when tices and operational components, including policies the person is at risk for dangerous alcohol withdrawal and procedures, mission statement, guidelines for syndrome, which can be lethal. referring parties (such as triage criteria for emergency medical system providers), intake assessment and Distinct from detoxification, sobering centers are not monitoring guidelines, and proposed or established intended to result in full cessation or abstinence of evaluation metrics. Last, site visits were conducted for a substance. As the name implies, sobering centers many programs; due to COVID-19 shelter-in-place aim to sober clients from the unstable and possibly restrictions, not all centers were visited during 2020. dangerous acute intoxication without then having to manage alcohol withdrawal or treatment services. Sobering is sometimes referred to as "pre-detox," where the care is aimed primarily at the risk of acute Findings intoxication before signs or symptoms of withdrawal. As of November 2020, 10 sobering centers are cur- Referral from sobering to detoxification services can rently in operation in California, with another six to often be facilitated when treatment is desired. eight additional programs being considered or imple- mented (Figure 1, page 6; Table 1, page 7). Two The second model commonly confused with sober- centers ceased operation during 2020, one directly ing center care is care received in sober living houses. related to COVID-19 restrictions and the second likely Sober living houses provide a group residential setting related to budget fluctuations and reprioritization due for participants in recovery who are abstinent from all to the regional impact of COVID-19 (Table 2, page 7). drugs and alcohol.16 A person may reside in a sober Leadership and key stakeholders from 9 of the 10 cur- living house for many months, often as a final tran- rently open sobering centers participated in interviews sition from substance use treatment back to home. for this environmental scan. Additionally, interviews Typically, substance use of any sort is not tolerated in were conducted with staff and stakeholders from one a sober living facility. of the recently closed centers and a sobering center currently in development. There was notable variety in the sobering centers throughout California, including the staffing configu- ration, facility layout, funding sources, and services provided. Yet commonalities, including harm reduc- tion focus, client-centered care approach, operations, and the principal role of sobering as part of the sub- stance use continuum of care, were prominent. Sobering Centers Explained: An Environmental Scan in California www.chcf.org 5 Figure 1. S obering Centers in Operation in California, as of November 2020 Bakersfield Recovery Station Del Norte Bakersfield Siskiyou Modoc Kern County Cherry Hill Sobering Center Trinity Shasta Lassen San Leandro Alameda County Humboldt Tehama CREDO 47 Stabilization Center Plumas Santa Barbara Mendocino Glenn Butte Sierra Santa Barbara County Nevada Lake Colusa Yuba Placer David L. Murphy Sobering Sutter Center El Dorado Sonoma Napa Yolo Los Angeles - Skid Row Sacra- Alpine Solano mento Amador Los Angeles County Marin Calaveras Tuolumne Contra San Costa Joaquin Mono Delano Recovery Station San Francisco Alameda Stanislaus Mariposa Delano San Mateo Santa Kern County Clara Merced Madera Santa Cruz First Chance Sobering Center San Benito Fresno Inyo Burlingame San Mateo County Tulare Monterey Kings McAlister Sobering Center San Diego San Luis Kern San Diego County Obispo Santa Barbara San Bernardino Mission Street Sobering Center San Jose Ventura Los Angeles Santa Clara County San Francisco Sobering Center Riverside Orange San Francisco San Francisco County San Diego Imperial Sun Street Sobering Center Salinas Monterey County Note: See the appendix for profiles on each of the ten sobering centers. Source: Qualitative research conducted by Shannon Smith-Bernardin, PhD, RN, 2020. California Health Care Foundation www.chcf.org 6 Table 1. Planned or Potential Sobering Centers in California, as of November 2020 ANTICIPATED COUNTY CITY STATUS OF PROJECT OPENING DATE Contra Costa TBD Initially approved for funding in 2016. Location not approved, and project TBD on hold until location identified. Last update summer 2020. Los Angeles Los Angeles Downtown Safe Haven. Construction delayed due to COVID-19. Early 2021 Los Angeles Long Beach Pending; continued discussions in Long Beach as of mid-2018. TBD Los Angeles Willowbrook Pending location at MLK Campus - in discussion mid-2018. TBD Mendocino Ukiah Part of a larger Safe Haven Clinic Initiative colocated with street medicine, TBD medical respite, outpatient pharmacy. Orange TBD In active planning stages throughout 2020. TBD Sacramento Sacramento Sobering center aimed at methamphetamine intoxication announced in TBD summer 2020. San Diego Oceanside Expected opening fall 2020. Fall 2020 Shasta Redding Conversation with sheriff January 2020 indicates still in planning stages. TBD Table 2. Sobering Centers in California That Permanently Closed in 2020 COUNTY CITY CENTER NAME DATES OF OPERATION Santa Barbara Santa Barbara Santa Barbara Community Sobering Center Opened: 1994; closed: March 2020 Santa Cruz Santa Cruz Janus Sobering Center Opened: 2015; closed: July 2020 TABLES 2 AND 3: Note: TBD is to be determined. Source: Qualitative research conducted by Shannon Smith-Bernardin, PhD, RN, 2020. Sobering Centers Explained: An Environmental Scan in California www.chcf.org 7 Commonalities Location. Facility layout, general location, and colo- Sobering centers in California serve adults age 18 cation varied. Approximately half the programs were years and older, and all but one program is currently stand-alone, while others were colocated with medi- open 24 hours a day, 7 days a week, 365 days a year. cal respite, detoxification, behavioral health services, The average length of stay ranges from 7 to 12 hours, or reentry services. Sobering dorms were segregated while the maximum length of stay for many centers by gender, with two facilities offering limited indi- was 23 hours and 59 minutes due primarily to behav- vidual rooms in addition to the often-larger dorms. ioral health or shelter funding, or licensing regulations Three facilities indicated they offer crates if the person restricting care to under 24 hours. Three centers stip- intoxicated has a dog or cat, to safely accommodate ulate a minimum four-hour stay. Length of stay was even those companion animals not certified as service flexible based on individual client needs; for example, animals. preventing alcohol withdrawal (i.e., shortening the stay) or transitioning clients to after-care resources (lengthening the stay) such as detox bed availability, Funding case management, or an urgent care clinic. There is considerable diversity in the funding of sober- ing centers. A number of California sobering centers were initiated through state or local funding streams Key Differences focused on diversion from the emergency department Staffing. Staffing patterns were considerably diverse and jail, criminal justice reform, or improved mental among the sobering centers. Allied medical per- health care access. As will be discussed later, many sonnel, such as medical assistants or emergency centers indicated that the procurement and sustain- medical technicians, were staffed at most but not all ability of funding streams was a significant challenge. the centers. Half the sobering centers employ licensed vocational or registered nurses, with two offering reg- These featured state-level grants offer support for istered nurse support 24 hours a day. Other centers sobering centers: employ nonclinical personnel to complete intake and $ Whole Person Care Program, the Medi-Cal Waiver ongoing assessments throughout the client stay, fol- Initiative. Three counties (Contra Costa, Los Angeles, lowing specific criteria and guidelines. The presence Santa Clara) were awarded five-year Whole Person of security likewise varied, with half the centers featur- Care grants in the July 2016 application phase; two ing staff in a security role. successfully initiated services (David L. Murphy in Los Angeles and Mission Street Sobering Center in Referrals. All centers currently accept intoxicated San Jose), while one county redistributed the funds people originating from the criminal justice system; to a related project after an unsuccessful attempt additional referral sources differed by center. As noted to find a location suitable to the program and com- in the appendix , common referral sources included munity (Contra Costa County). emergency departments, outreach teams, and ambu- lances. The ability to accept walk-ins or self-referrals $ Proposition 47, "No Zip Code Left Behind." contrasted by community. Certain centers indicate that Approved by California voters in November 2014, in they were restricted from accepting walk-ins based on part it reduced a number of low-level drug offenses agreements instituted during center implementation, from felonies to misdemeanors. The provided fund- while other programs reserve walk-in ability to those ing can support public agencies in providing mental well known to the centers, with active engagement health services, substance use disorder treatment, and care management plans. or jail diversion. Both Sunstreet Sobering (Salinas, Monterey County) and CREDO47 (Santa Barbara County) receive Proposition 47 funding. California Health Care Foundation www.chcf.org 8 $ Proposition 63, Mental Health Services Act $ Medi-Cal Administrative Activities Recorders, Innovations. The grant, administered by the which provides a small per diem rate when eligible California Department of Health Care Services, people are screened for and referred to expedited is designed to expand and transform California's county services such as Medi-Cal. behavioral health system to better serve those with or at risk of serious mental health issues. The Additional funding options identified as potentially Kern County sobering programs (Bakersfield and viable but that have not yet been obtained include: Delano) each receive MHSA Innovations funding. $ Gaining certification as a Drug Medi-Cal site to increase availability of substance use–related $ Edward Byrne Memorial Justice Assistance Grant. interventions This primary block grant funding stream is available to state and local criminal justice agencies and the $ Statham funding (PC 1463.16), originating from courts. It has been used previously by sobering court fines related to "drinking driver" convictions, care efforts in Escondido (San Diego County); these can be used toward the development of privately sobering services are no longer in operation. operated programs at the local county level in alco- hol-related interventions Some financing was initiated through county funding streams: No sobering centers are currently directly billing those served nor are they billing insurance companies. $ Alameda County's Measure A "Essential Health Care Services Tax Ordinance," approved in 2004 to allocate a half-percent sales tax toward a number of Best Practices public health interventions California sobering centers share a number of promis- $ San Diego County Behavioral Health Services pro- ing practices that sustain and support their work. Four vides funds to McAlister Institute, the organization primary themes emerged from the key informant inter- that runs the San Diego sobering center17 views: (1) using a low-barrier, compassionate service model; (2) providing clear protocols and streamlined $ Santa Cruz County Sheriff's Department services; (3) playing a central role in coordinating cli- $ City and County of San Francisco general fund ent care between city- and countywide agencies; and (4) being flexible with programming. To augment support and to provide additional ser- vices to sobering center clients, many centers have Low-Barrier, Compassionate Service Model pursued smaller funding streams, including these: Key informants discussed their ability to operate as a very low-barrier facility while treating clients humanely $ Medication-Assisted Treatment (MAT) Expansion with respect and dignity. Low-barrier services promote Project, aimed at increasing the number of MAT an easily accessible and user-friendly environment, access points in California. minimizing barriers such as paperwork, eligibility $ Prosecution and Law Enforcement Assisted requirements, and complex intake processes. Key Diversion Services (PLEADS) is a pilot model pro- informants expressed their goals to "meet people gram accepting a specific target population under where they are at" and create a welcoming environ- the influence of substances other than alcohol, ment that is trauma informed, nonjudgmental, safe, primarily methamphetamines and heroin. PLEADS with a harm reduction focus. Key informants expressed is a collaboration in San Diego County between the importance of initially enlisting a leadership team County Behavioral Health Services, the city attor- (administrators and managers) who understand and ney's office, and the police department. support low-barrier, easy access, and harm reduc- tion efforts who then hire frontline staff dedicated to Sobering Centers Explained: An Environmental Scan in California www.chcf.org 9 the same mission. This initial focus on recruiting the Centers that monitor a restriction-of-service list indi- right team - from leadership to frontline staff - was cated between three to six people would be on the expressed as critical to developing and implementing list at any one time. a successful service model. Staff training is critical to successfully developing this An example of this best practice is that programs culture. Training topics noted to be of particular value make considerable effort to accommodate people included risks and complications of acute intoxica- despite disagreeable behavior, only rarely perma- tion, de-escalation, substance use disorders, mental nently restricting them from returning for services. For health conditions, motivational interviewing, trauma- example, those with a violent or threatening episode informed care, and harm reduction practice. Many would be either provided a short-term restriction from interviewees emphasized incorporating staff with lived sobering services (typically a few weeks) or would be experience (in substance use disorders, mental health, assessed at each visit to determine risk of violence. and/ or homelessness) for direct client care, engage- Some programs utilize a safety committee of frontline ment, and guidance. It was noted this staff need to and managerial staff who regularly review behavioral be in a position to have a pivotal role with the intoxi- incidents. A second reason for permanent restriction, cated person during their sobering stay, rather than as will be discussed further in the "Challenges" sec- relegated to indirect roles such as janitorial, kitchen, tion, involves those with severe alcohol use disorder or outside security. suffering from significant health and cognitive decline. Particularly for centers that have been in operation a Clear Protocols and Streamlined few years, some regular sobering services participants Service Provision were eventually restricted due to chronic decline in Key informants stated their goal is to admit and retain health requiring substantially higher care, such as people for successful sobering from intoxication, skilled nursing or one-to-one client-to-staff ratios. and the intake process is as streamlined and easy as possible. They indicated that clear eligibility criteria and field screening tools, admission and assessment guidelines, and a streamlined admission process were critical to their success. They recommended limiting "Everybody is treated with a high level of or eliminating any intake paperwork required of the respect and dignity, and more often than intoxicated client, citing a priority to reduce unneces- not, it's just people who made a poor sary agitation of the client while intoxicated. Referring parties likewise benefit from the rapid intake process, decision. They're not bad people out doing allowing first responders to seamlessly complete the bad things. They're not criminals. So we do transfer and quickly return to the field. For law enforce- ment, the intake process is typically under 10 minutes a lot of education the short time that they're compared to 60- to 120-minutes at jails. here with us, so hopefully they don't find While offering a fast referral process, the intake must themselves in this predicament again." assess all incoming clients for higher-level medical - Program director or psychiatric needs. Those requiring such care are referred to the appropriate resources. California Health Care Foundation www.chcf.org 10 Central Role in Care Coordination "One of the biggest positive things that Key informants noted that their centers function as a hub in the continuum of care for people with sub- comes out of a sobering center that runs stance use disorders, navigating between multiple 24/7 and that's staffed with recovery agencies including health care, behavioral health, criminal justice and probation services, and homeless specialists and people who are educated services. Factors that facilitate effective coordination or have a background in SUD is that . . . include around-the-clock staffing, the ability to hold and engage clients for enough time to support direct no matter what time of day you call, transitions into stabilizing services including treat- whatever time of day it is, you're going ment, staff specialized in substance use disorders, to get somebody on the phone who can and extensive community partnerships. Operating 24 hours a day, 7 days a week allows for immediate direct you. Who can help you." response to those in crisis, timely communication with - Program director other service providers, and the ability to keep people on-site until other services are open for direct linkages. Staff specialized in substance use disorders and "One of my favorite stories. . . . There was a knowledgeable about available resources were critical lady that came in, kind of a frequent flyer, to these efforts, recognizing when a patient is ready homeless, just a sad, sad state of affairs. The for the next step and providing referrals to detoxifi- cation or other treatment services. Common services staff are cutting and peeling the socks off of provided to aid in care coordination include screening her feet, and if you could just picture these for substance use disorders, assistance with prescrip- tions, intensive case management or care navigation, two young women. Gently washing her feet vulnerability assessments, and referrals to housing and and talking to her and saying, 'Honey, you benefits. don't have to live like this.' Just the kind of Effective care coordination approaches can position care and compassion that she received in sobering programs to be a key player in promoting the sobering center rather than going to systems integration. First, many sobering centers offer comprehensive coordination for frequent users jail was heartwarming and just powerful. of community systems, including emergency services Those are the unseen social connections and EDs, psychiatric emergency services, and commu- nity paramedicine teams. In particular, key informants and caring. . . . discussed the ability to engage with people who are homeless, provide on-site hygiene and support ser- When I talked with staff about it, they said, vices, and assist in navigating community resources such as shelter services, entitlements, or health access. 'That's somebody's mom. What if it was my Additionally, sobering center leadership reported par- mom, and my mom was somewhere else and ticipating in weekly or monthly case conferencing needed help.' They really treated her just as meetings with service providers from community- and hospital-based organizations. they would want their own mother treated had she been in the similar situation." - Program director Sobering Centers Explained: An Environmental Scan in California www.chcf.org 11 Programmatic Flexibility "It's a multi-institutional organization of which Last, key informants noted the importance of pro- the sobering center is at the epicenter." grammatic flexibility and the ability to meet the needs of the clients and the community at large. Individual- - Medical director level flexibility was reflected by centers offering longer stays on a case-by-case basis, accepting people altered Second, within the behavioral health continuum of from multiple substances in addition to alcohol, pro- care, sobering centers can augment the mental health viding overnight shelter to people released from jail system, providing care coordination and support during inhospitable weather, or assisting in the care in the care of intoxicated adults with mental health of those of high need or high risk who may not meet needs. Programs indicated up to 60% to 70% of those standard eligibility criteria (e.g., an unintoxicated adult served report co-occurring mental health diagnoses. experiencing homelessness with a housing interview By providing short-term sobering for clients with dual the following morning). diagnoses, programs can re-refer clients directly to the mental health care system, which can engage more On a larger community level, one program director successfully. noted that their center created a sobering-based out- reach team to better serve the local community, locate Care coordination is supported in some centers by more people at greater risk of harm related to their comprehensive access to electronic records within the public intoxication, and increase census. Another col- sobering center, with the ability to view community laborated with rehabilitation centers to receive those data on the clients (health records, case manage- who had relapsed in treatment. The sobering center ment, to assess document readiness for housing, would provide short-term sobering, access to showers etc.). However, community-level data were not imple- and laundry, and then return the person to their treat- mented at every center, and for many the access was ment program within one day. read-only, so the sobering staff was unable to provide updates or longitudinal information regarding services Program leadership did note that flexibility, how- provided. ever, was strongly influenced by whether the funding stream allowed the center to be nimble in its service provision. "I just think flexibility, learning to roll with Additional Strengths and Advantages of the the punches, and if you have to change Sobering Care Model the model that you designed originally or Throughout the interviews, leadership noted addi- that you started with . . . to reach a greater tional strengths and advantages of the sobering care model and some notable successes. First, all the pro- number of people to help, just be willing to grams noted low rates of those served in a sobering roll with those punches and don't sit there center requiring transfer to the emergency depart- ment - generally less than 5% of discharges, which and wait for census when there's things you was credited to strong admission criteria, comprehen- can do to get out and create census." sive staff training, and specific medical protocols for intake and monitoring. - Program director Many programs noted moderate to high rates of recid- ivism by those with chronic alcohol use as a sign of strength, reflecting positively on the program having earned the trust of both a disenfranchised population California Health Care Foundation www.chcf.org 12 and the parties who refer these clients to their care. benefit and thus funding could theoretically be lev- Additionally, the sobering model lends well to facil- eraged from various sources. Yet many parties that ity colocation with other community services: mental benefit from the care of intoxicated people do not health crisis stabilization, homeless health care (such have obvious moneys to contribute (such as univer- as medical respite), or detoxification. sities for care of intoxicated students), or shared memorandums of funding streams are unable to be Last, most sobering centers are operated by nonprofit negotiated. organizations well established in either the mental health or substance use continuum of care. These Much of grant funding secured is short-term, imposing centers note a streamlined access to services, such as precariousness to the implementation and sustain- detoxification, psychiatric urgent care, and substance ability of sobering services. Many funding streams use treatment including access to medication-assisted that offer support for sobering services were noted to therapies and psychiatric medications. be limited to a specific use and often do not permit integration between substance use, mental health, medical care, or criminal justice services. Challenges Despite the use of emergency departments for Key informants noted that the success and sustainabil- uncomplicated acute intoxication, an ED may success- ity of sobering centers were met with core challenges, fully bill certain insurance providers for this care and including: (1) securing long-term funding, (2) stigma obtain payment higher than cost. In this scenario, a and lack of community acceptance, (3) the disjointed profit is realized. Thus, the hospital may be financially nature of the behavioral health system, (4) misunder- disincentivized to partner with a sobering center to standing of the sobering care model, (5) difficulty reduce their census of acutely intoxicated patients. achieving buy-in of referring parties, and (6) providing care to a population with increasing care needs. Stigma and Lack of Community Acceptance Funding Securing a facility to operate a sobering center in was Sobering centers are not intended to be profitable. identified as a significant challenge by all newer cen- They generally provide cost avoidance from higher- ters (in operation less than four years). Key informants priced services (such as those provided in EDs) or by noted that substantial time and effort was required to saving first responder time (including decreased "wall identify, achieve community approval for, and build out time" [ambulance patient off-load time]18 for para- locations provide sobering services in. They also sug- medics or the previously mentioned reduction in law gested that behind these difficulties lay stigma about enforcement time for transfer of intoxicated people). alcohol use and discrimination toward intoxicated Despite the potential benefits to a community from people, including and especially toward those with operation of a sobering center, securing and maintain- co-occurring homelessness, mental illness, or histories ing funding of sobering care services was identified as of incarceration. Community pushback in the form of a significant challenge by numerous centers, including "NIMBYism" (not in my backyard) was often exposed dependency on grant or static funding. during the design and implementation phases of establishing a sobering center and was generally A critical funding challenge often noted by key infor- expressed as fear that a site will lead to unwelcome mants is a disconnect between the entities that benefit populations being attracted to or abandoned in the from sobering centers and the entities that fund sober- respective community. In some cases, this pushback ing centers. This disconnect impacts sustainability, as led to substantial postponements in operation launch, cost benefit analysis may indicate multiple parties with upward of two- to three-year delays, and some Sobering Centers Explained: An Environmental Scan in California www.chcf.org 13 even led to the full cancellation of the centers despite "We have to look at the ubiquity of complex securing funding. problems. We have to look at substance use disorder as not being something apart from "They [some community members] get upset mental health. We really do have to deal over the way their city looks, but they're with that, and it's difficult because we have not willing to put in the effort, or just the laws and regulations to segregate things, voice to what works. . . . They just get stuck and we do." on this idea that it's an eyesore, or that it's - Program director going to bring in a bad population. They don't read the tape all the way through to Sobering Care Model Misunderstood see what the nice endings look like. And so Many centers indicated that community members that's the frustrating part, to me." and stakeholders do not understand the activities and benefits of a sobering center, and that the concept - County administrator of sobering centers in general is too abstract and ill- defined. Despite sobering centers often functioning Certain centers noted that when finally located, they within a community's continuum of behavioral health were placed in neighborhoods that were more danger- care, many do not recognize or understand its value. ous, undesirable, or far from resources and after-care options. "I still think the world in general is very Disjointed Behavioral unclear on what the sobering model is Health "System" exactly. I know that's always the first Within the systems of care, providers struggle with question that someone asks us when they the largely distinct treatment and care environments for mental health versus substance use. Key stake- come visit, or they come on a fact-finding holders indicated difficulty in engaging with mental mission. Exactly what is the sobering health providers and programs that did not have the model, because it's very easy to mix capacity to provide care to those with both a mental health diagnosis and active substance use. As noted up with residential detox or detox, and by one director, "The world of alcohol and drugs . . . people just don't truly understand the there's still a blood and guts kind of street world that is getting more and more sophisticated, but it's still not sobering concept." really integrated with mental health enough." - Program director Yet many expressed that care coordination - includ- Leadership expressed a need to outreach to com- ing colocation of sobering services and behavioral munity members and key partners, as the changing health crisis management - can directly decrease political climate, gentrification of neighborhoods, provider stigma, improve management of co-occur- or funding mechanisms required constant engage- ring conditions, and improve individual care. ment. Despite this outreach, requests to reduce or alter sobering services to assist in unrelated projects California Health Care Foundation www.chcf.org 14 or populations were frequent. Particularly for cen- "I think our sobering center is seeing people ters with a greater demand than capacity, sobering center leadership indicated a need to constantly bal- who are being failed at every level of our ance the ongoing requests while staying true to their system and our society and are often mission and not decreasing care for their intended populations. difficult. They're difficult people to be with a lot of the time, and I think there is a Achieving Buy-In with desperate need for advocacy. When I say Referring Parties bearing witness, I don't just mean bearing While some centers indicated they had space limita- witness to the client who is going through tions and were often exceeding capacity, newer programs (open less than one year to five years) indi- this, but I think also bearing witness to the cated a slow start-up, with lower than anticipated system. That this is the way our system utilization and ongoing need to obtain buy-in from referring parties. is failing people, who are so profoundly vulnerable. Newer programs indicated at least 12 to 24 months of full-time operation before anticipated census numbers were reached. Sobering leadership stated resistance I think that's tremendously important work, and difficulty changing preexisting beliefs of referring because these are human beings and they parties. Specific to law enforcement, achieving buy-in are literally about as vulnerable as anyone in often requires a considerable cultural change to the mindset that "a person behaving badly deserves to go this country ever, ever, ever, ever is, and no to jail" for which a sobering center visit is not punish- one deserves to die on the street like that." ment enough. - Medical provider Efforts have been made to reduce hours to be more cost-efficient. However, this is confusing for both the referring parties seeking services on off days and for continuity of care. "It's the outreach with the law enforcement agencies, educating them, talking to them. And from my standpoint, what I've seen is . . . officers that are longer-time officers maybe would have been a little more hesitant . . . resistant in bringing the young ones in. And I think once they touch it, see it, feel it, they're in there. They're seeing how we are on intake. I can't tell you the number of times I've had officers just look at me with this very soft face all of a sudden, and they just go, 'You're an amazing person to do this.' It's really interesting to me, the feedback we get from them, because they see them [the intoxicated people] in a different light, in a different way. They have a different outcome if they do take them to jail versus bringing them, and they see what we do." - Nurse coordinator Sobering Centers Explained: An Environmental Scan in California www.chcf.org 15 Population with Increasing medical staffing found current funding streams were Care Needs not enough to expand substantially into a medically Leadership and medical providers noted the enhanced model. mounting challenges to serving a medically fragile population in declining health that faces increasingly Lack of After-Care Services greater needs - yet is not able to access appropriate Finally, there was consensus around a lack of resources care. Functionally, many in this population transition available to offer clients interested in stabiliza- between homelessness, the sobering center, and tion, including detoxification, residential treatment, emergency services without long-term stabilization. housing, and long-term care. Without adequate detoxification beds, emergency shelters, or residential Staff struggle with the question of what the options facilities, sobering centers do not have many options are for someone unable to be stabilized within the cur- to assist in on-site long-term stabilization. This may rent system of care. Key informants indicated a lack of result in some clients rotating in and out of short-term appropriate facilities to help arrest the decline of those services, sometimes for years. at high risk of hospitalization, incarceration, trauma, or death. Many are unplaceable in traditional settings (e.g., board-and-care or skilled nursing facilities), yet are too impaired to live in independent housing. Effect of the COVID-19 Pandemic on Sobering This leads to sobering care that is often split between two populations with very different needs. The first Centers are the "high-need" clients - those with chronic Sobering centers function in a congregate setting, intoxication, cognitive impairment, or co-occurring and all sobering centers modified or restricted service homelessness who are severely disorganized. The in response to the COVID-19 pandemic and resulting second population is more functional - they may be health and shelter-in-place recommendations. The housed or homeless, yet they can function indepen- response to COVID-19 has primarily affected capac- dently. They only require a safe space to metabolize ity, with reductions to accommodate social distancing. alcohol and do not need intense services. Thus hold- Additionally, some centers indicated a change in pop- ing beds nightly for those with no other residential ulation. One center at the time of this report continues option takes up beds also needed for those who may to provide services exclusively as a COVID-19 isola- only require a few hours of sobering. tion and quarantine site for those with suspected or confirmed coronavirus; all sobering care services have Leadership expressed a critical need for very low- temporarily ceased. barrier residential facilities to accommodate the high-need sobering clients, including palliative care, Challenges specific to operations include an interrup- medical respite, and managed alcohol programs. tion of the traditional lines of communication, reducing the ability for sobering leadership to engage with referring parties for education, training, and care coor- Areas for Improvement/Expansion dination meetings. Funding is anticipated to be more A number of areas for improvement or enhancement precarious, as budgets throughout the state have were shared by key informants. taken a substantial hit due to COVID-19. Additionally, for nonprofit organizations operating sobering cen- Staffing ters, general organizational funding may be reduced Key stakeholders expressed interest in enhancing as community members who would typically donate staffing with medical personnel, such as nurses or to nonprofits do not have the capacity this year. paramedics. Yet many centers with basic or no on-site California Health Care Foundation www.chcf.org 16 On a positive note, one center shared incredible Center Design and Development progress serving their most frequent clients through Up-front building investments can be substantial and the creation of a targeted managed alcohol program must be included in initial budgeting, including facility colocated with their sobering center.19 Initiated to build-out and safety and code improvements. support shelter-in-place by those with chronic alcohol consumption, high-use sobering clientele who partici- In part for budgetary reasons and previously noted pated in the managed alcohol program were noted community resistance, some communities opted to to achieve levels of stabilization not previously seen, pursue a county-owned building in which to house a including reduced interaction with the emergency sobering center. Locating it on county property has medical system, adherence to medication manage- benefits, yet a few core challenges were expressed. ment, decreased levels of intoxication, and increased These include the inability to use 911 or police nights sheltered. response for on-site emergencies, as county proper- ties are within the sheriff's catchment, which may offer less rapid nonemergency response. An arrangement Further Developing the that indicates county employees must be used for staffing needs may impact both staffing budget and Role of Sobering Centers the ability to contract with an established community organization. Last, many stakeholders voiced ongoing Throughout California tensions between county and city organizations, lead- Sobering center leadership, in particular those in ing to disagreements on which organizations would newer programs, outlined a number of critical aspects be permitted to refer people to the sobering center if to successful design and implementation of new located on county property. sobering centers. Community Engagement Visiting Sobering Centers Some stakeholders likewise stressed the importance First, connecting with and visiting existing sobering of the support of the community in the early stages of centers - both in California and more broadly within development and throughout the process of initiating the United States - was critical to choosing an appro- operations. This community engagement is recom- priate model, identifying potential challenges, and mended regardless of funding stream, contracted assessing recommended practices for local imple- partners, or mission. The most effective engagement mentation. Each sobering center operates differently practices include proactively pursuing face-to-face than others. Key informants indicate this ability to meetings to offer education about the goals and deep dive into the distinct models was essential to the anticipated impact of a sobering center, identifying successful development of their centers. needs, and addressing concerns of community mem- bers. This includes outreach and engagement with Current sobering centers can offer example paper- community leaders, county and city leadership, busi- work and information on medical protocols and ness associations, the county board of supervisors, data collection. For example, many centers refer- criminal justice stakeholders (city, county, and state law enced the medical protocols originally created at the enforcement agencies, district attorney, and public San Francisco Sobering Center, which were distrib- defender), broader mental health and substance use uted to numerous other programs both in California treatment services, and neighborhood organizations. and nationwide to be modified by their respective communities. Sobering Centers Explained: An Environmental Scan in California www.chcf.org 17 Messaging center is the primary clinical program, then it is unlikely Many key stakeholders noted a need for increased to be eligible for FQHC status. messaging about the role of sobering centers in the continuum of care. Much of this work requires contin- Efforts toward accreditation or licensing may be more ued efforts to "step up" the reputation of sobering critical for sobering centers intending to take intoxi- centers both in California and in the United States. cated people directly from the 911 ambulance system as an alternative destination to the ED. Sobering cen- They recommend a coordinated information cam- ters receiving clients exclusively from law enforcement, paign detailing the specific activities within a sobering the ED, and street and homeless outreach teams may center, role in the system of care, distinction between not require additional oversight than currently pro- sobering and related care models, and how each vided. AB 1544, the "Community Paramedicine and center supports its clients and the community at Alternate Destination Act,"20 legislatively paves the large. Additional content ideas included details on way for many communities to consider ambulance safety of the sobering center for those served, types referrals, while the Centers for Medicare & Medicaid's of enhanced care compared to alternate services ET3 (Emergency Triage, Treat, & Transport) Pilot offers (jail, ED), and specifically how the center is positively billing capability for transports to non-ED destina- impacting the community. tions.21 These options may allow a sobering center to be designed with EMS referrals in mind, while not As indicated, there is an ongoing, frequent need to opening to all other referring parties until accredita- educate referring parties and the community about tion or appropriate licensing can be achieved. the work and goals of a sobering center. Notably, this was expressed as both a best practice and a chal- lenge; as stated by one program director, the "job is never done." Recommendations to Promote Adoption of Monitoring and Oversight Sobering Care Model There are currently no certification or accreditation programs for sobering services specifically. Many in California organizations who run sobering centers do have A number of components are recommended to pro- accreditation for some or all of their nonsobering mote the successful implementation and expansion of programs, such as detoxification, rehabilitation, or sobering centers in California. behavioral health interventions. The primary goal of accreditation is to gauge a health care facility's abil- ity to live up to predetermined industry standards set Lower Barriers to Make by veritable bodies within their field. Accreditation is Services Accessible awarded by entities, organizations, or associations not All efforts must support a fully accessible, low-barrier affiliated with any government. model of the sobering center. A critical aspect of sobering care is the ability to broadly serve adults who If the center is associated with a well-developed com- may be intoxicated in public: insured and uninsured, munity organization with additional clinical services documented citizen or not, housed or homeless. In that performs billing within the health care system, addition to supporting equitable access, this ensures such as a primary care or urgent care clinic, pursing frontline responders can triage intoxicated people status as a satellite of the existing Federally Qualified based on actual need and refer to the most appropri- Health Center (FQHC) may be feasible. If the sobering ate level of care. California Health Care Foundation www.chcf.org 18 Sobering should be welcoming and engaging, not partnership with law enforcement via jail diversion, punitive. Due to stigma, those with long-standing a sobering center can reduce contact with the crimi- substance use - particularly those with co-occurring nal justice system and provide more direct access to homelessness - are often dehumanized. They face substance use services for those with harmful sub- incredible stigma both overt and subtle. The sobering stance use. environment is often the only setting where people with chronic public intoxication are consistently A broader range of agreements may offer greater accepted as they are and treated with compassion. care coordination capability and enhance services This culture will impact the person's willingness to provided (e.g., reserved patient slots at urgent care, engage and consider options to change harmful shelter beds, or medication-assisted therapy intake behaviors. appointments for sobering clients). That said, although increased connection to the Last, any sobering center must allow for some flex- substance use system is a goal, many clients do not ibility in the specific design, implementation, and initially accept direct transfer to treatment. Most intox- ongoing modification of services offered and popu- icated people referred to a sobering center are not lations served. It is important to establish a sufficient actively seeking care - they are brought in while in a catchment area with ample referring parties to both symptomatic phase of their condition. A majority will capture the populations requiring sobering care and utilize the sobering service, safely recover from acute to achieve capacity. Set appropriate expectations intoxication, and return to their communities. For that buy-in takes time; experience by sobering cen- many, the active engagement of staff through motiva- ters statewide indicate that initial utilization is typically tional interviewing and a compassionate approach will lower than anticipated and that the anticipated census encourage behavior change. may be achieved over a 12- to 24-month period. Improve Partnerships with Referring Entities During the design and preparation phases of open- "We ultimately are providing them a safe ing a sobering center, key stakeholders should actively place where they know people care. That's engage with the frontline responders expected to a lot of the feedback we do get from refer intoxicated people. Ideally occurring early in the process, this engagement can take the form of ride- our participants. . . . They can come in alongs with field paramedics and law enforcement, intoxicated and in crisis. And to just have observation of emergency department staff and oper- ations, focus groups, and key informant interviews. feedback from actual individual participants This targeted exploration will provide the opportunity to our staff of, 'Wow, we need more people to promote buy-in by establishing trust, identify unmet needs of referring parties and their clients in use of a like you because I feel like a human being. I sobering center, and work to resolve any needs and feel like you're talking to me like a person.' concerns of referring parties. And they don't always get that when they're Increasing the focus of sobering centers in the diver- homeless and having addiction issues." sion of emergency services is supported by published - Charge nurse research.22 Even so, it is not recommended to restrict sobering care access only to emergency services. In Sobering Centers Explained: An Environmental Scan in California www.chcf.org 19 Ensure Sustainability Evaluate Sobering Center Impact A promising option for financing is billing through the Sobering centers can function well as part of con- In Lieu of Services mechanism within California's Medi- tinuum of care, yet they are not anticipated to be Cal reform proposal - CalAIM (California Advancing profitable. Evaluations ought to consider outcomes and Innovating Medi-Cal). In Lieu of Services (ILOS) are such as cost avoidance (e.g., unreimbursed ambu- flexible wraparound services aimed to address medi- lance transports or ED visits, jail encounters), staff time cal or social determinants of health needs, instead of efficiencies (e.g., reduced hand-off at sobering cen- (in lieu of) more expensive emergency room stays or ter vs. other destination), individual-level outcomes preventable hospital stays.23 Sobering centers are one (e.g., reduction in ED visits for high-need clients), and of 14 ILOS approved by the state. related factors (e.g., staff satisfaction, reduction in injuries). As a population health strategy, sobering centers function to decrease reliance on the more costly alter- Likewise, process evaluations can gauge how a sober- natives of care (e.g., ED visits for acute intoxication) ing center augments and enhances service provision while introducing more targeted services based on in the continuum of care. Most notably, linkages to population need. ILOS has the potential to address after-care and stabilizing services should be assessed. many of the sustainability challenges faced by sober- Examples of this includes connection to case man- ing centers. Managed care plans will likely receive agement services, initiation of medication-assisted incentive payments to help build capacity for ILOS. therapies or injectable antipsychotics, or the provision These dollars could help to support facility build-out, of primary care and wellness services for the higher- staffing, and operations. Sobering centers would then use clients. need to create infrastructure to bill for encounters and report data to their contracted managed care plans. Establish Data Management Systems "We have too many square holes for our There was substantial variation reported in data col- lection and charting capabilities. Many sobering round pegs, and so advocacy and bearing centers are collecting data either on paper or on witness to the system that says, 'This is local electronic spreadsheets and remain electroni- wrong to let people suffer in this way.' If cally disconnected from the larger system. Many key informants indicated a need to implement a robust you can't see that it's wrong, at least see yet functional database, though they did not have the that it's expensive for your system and it resources to develop their own system. overburdens your system in places that Larger electronic health records used by hospital sys- it doesn't have to be overburdened. If tems could offer charting capability, though some may be too complicated or not specific enough to capture sobering centers can help advocate up to and report sobering-level data, such as referring par- city, state governments to say, 'This is what ties, disposition, or screening and referral outcomes. we see, this is what we need. How can we Ideally, sobering centers would obtain access to a system that offers community-level charting and navi- get these things?'" gation for care coordination yet is specific enough - Medical provider for internal reporting of client outcomes, feedback to referring parties, and program evaluation. California Health Care Foundation www.chcf.org 20 To better coordinate sobering services across the Raise Awareness Among continuum of care, to bill Medi-Cal managed care plans, and to enhance quality improvement and Policymakers About Sobering quality assurance efforts, the development of more Services comprehensive data management tools is necessary. Finally, it is critical that state policymakers and deci- Considering the needs of sobering centers, as well as sionmakers leading efforts for (or interested in) the regional and statewide interests, this data manage- expansion of sobering centers in California enhance ment may benefit from the following features: their direct knowledge of sobering care. There would be great value in visiting a variety of sobering centers, $ Customizable permissions to control what users can both within California and across the country. These access at a granular level (this would allow users, visits allow for in-depth discussion with management based on their scope and role, access to some and frontline staff providing sobering care, a visualiza- forms and fields but not others, and could also be tion of how the center operates within the surrounding used to limit their access to a specific sobering cen- community, and the opportunity for conversation ter or to grant access to several centers). with related stakeholders including homeless health $ Shared standardized and templated forms, with the care, hospital, law enforcement, and emergency ser- ability to customize on the front end so local sites vices leadership. Additionally, the National Sobering can edit or create additional forms to meet their Collaborative offers resources for communities explor- local needs. ing sobering care including a targeted Community Needs Assessment, Tool Kit for Sobering Center $ A cloud-based system aggregating data from mul- Development, list of sobering-related research, and a tiple sobering centers would allow for statewide National Directory of Sobering Programs. assessment of care provided, the populations served, and - importantly - an ability to monitor drug use trends throughout the state. $ Visual dashboards and custom reports that include Recommended de-identified aggregate data from many sites (statewide, regions like Southern California, etc.). Collaborations/ Individual sobering centers could make changes Colocations for to their reports, or create additional reports, at the local level to support regional funders and commu- Sobering Centers nity partners. Depending on community and population needs, col- laborations or colocation of sobering services may $ Modern security features like multifactor authenti- offer substantial benefits. cation, password expirations, user activity logs for auditing purposes. $ A mix of technical support options including dedi- Homeless-Related Services cated project management, in-app chat support for Homelessness is common among people with acute users, and reporting assistance like writing custom intoxication, and centers providing sobering care database queries. should include services for people who are homeless. Alcohol use disorders cross all socioeconomic catego- Depending on funding streams and the broader ries, yet research indicates higher rates of ED use and expansion of sobering centers, local participation in a recidivism for those with co-occurring homelessness statewide data dashboard for the sobering care pro- and alcohol use disorders.24 It is estimated that 38% vided may be possible. of people experiencing homelessness suffer from severe alcohol use disorders, with over 80% of those Sobering Centers Explained: An Environmental Scan in California www.chcf.org 21 chronically homeless experiencing an alcohol or drug Suggested partnerships: Medical respite / recupera- use disorder during their lifetime.25 This co-occur- tive care, street medicine or street health teams, rence of homelessness with an alcohol use disorder homeless outreach, case management, transitional negatively impacts health26 and results in elevated housing providers, palliative care. mortality.27 This is important, because although EDs offer comprehensive medical care, most EDs do not have the resources, time, or expertise to offer targeted Behavioral Health longer-term interventions for patients with co-occur- Mental health care. The colocation and coordination ring substance use disorders and homelessness. with mental health crisis stabilization and sobering centers have brought notable successes. In addition to the new Santa Barbara County sobering center "We see people sometimes in some of their located alongside crisis services, three cities - Kansas City, Kansas; Kansas City, Missouri; and Baltimore, periods of their greatest suffering. You also Maryland - have colocated sobering centers with cri- then can see clients have the opportunity sis stabilization. This placement allows for a full range to thrive and do things differently and of conditions, from mild intoxication through psy- chosis (both behaviorally based and drug-induced). [sobering staff] can really play a role in Particularly for communities faced with a high number someone having an improved quality of life. of methamphetamine-related psychosis, this place- ment helps to limit the number of decisions a frontline Even in their worst moments, you know that provider needs to make in deciding where to transport you are contributing to their well-being in an altered person. It provides for an environment that can accommodate both more-acute clients requiring a meaningful way. So those are things that medication assistance for stabilization and those only staff reflect back . . . being able to sit with requiring rest and monitoring - providing flexibility them in some of that suffering." for changes in individual presentation or emerging care needs. - Nurse coordinator Substance use services. Partnerships may be with The role of a sobering center in caring for those with both abstinence-based and harm reduction–focused comorbid homelessness and substance use cannot be services. For example, colocation with a medical overstated. One-third of sobering centers nationwide detoxification program or an arrangement for direct indicated a focus on the person who is both home- transfer will decrease access barriers and increase less and frequently intoxicated in public, and it is likely treatment-oriented discharges for interested clients. other centers are serving similar clients. Practical on- Centers with prescribing providers may establish site interventions to improve quality of life can include buprenorphine starts and follow-up connection to shower and hygiene facilities, clean clothing, delous- ongoing medication-assisted treatment. ing care and medication, laundry, food, and oral rehydration. Care coordination services may include Suggested partnerships. Medical or social detoxifi- peer navigation, case management, and referrals to cation, residential rehabilitation, addiction medicine shelter or housing. Centers with access to licensed and nursing specialists, medication-assisted therapy health care providers may offer wound care and providers, outpatient pharmacy. chronic disease medication management, or provide for urgent care or primary care needs. California Health Care Foundation www.chcf.org 22 Emergency Medical System "We have had such success in our A most promising collaboration in California is the expansion of sobering services to accommodate refer- collaboration with the emergency medical rals from the 911 ambulance system. The Emergency system and the community paramedics. For Medical Services Authority has seen continued suc- so many years, I felt like we were still siloed, cess in the aforementioned alternative destinations pilot program. Looking at creating or modifying and we still are in many ways. But now, sobering centers to receive referrals from paramed- especially with our collaboration with the ics, EMS providers may need assurance that the care provided is safe and that there are robust protocols community paramedics. . . . both in the field and within the sobering center for individual assessment and monitoring. Clear, compre- I feel like we really just bridged that gap hensive screening tools and protocols are critical to the implementation and ongoing success in providing where everybody kind of sees the bigger sobering care to intoxicated people. picture. We're trying to do right by the system, but we're also trying to help these There are three key stages during the transition of an intoxicated person to a sobering center that offer the clients. And the community paramedics have opportunity to perform screening to ensure safety and really contributed to that. The collaboration appropriateness for care in a sobering center. First, clear eligibility and exclusionary criteria for potential with the emergency medical system has transfer to a sobering center. Second, thorough intake been so key. In not just the relationship and assessment performed at the sobering center before admission. And third, guidelines for the ongoing mon- not in the department, but the outcomes itoring of intoxicated clients during their sobering stay for the clients are so much greater than they including assessments for withdrawal, decompensa- were before because we can do so much tion due to polysubstance use, and protocols in case of emergency. more. We can connect longer-term rather than just the short term, which is what we In sobering center development, certain steps to pro- mote safety are recommended. First, sobering and focus on." EMS leadership should coordinate on developing - Charge nurse triage and monitoring guidelines that are evidence- based and specific to local resources. Research on Last, support from EMS leadership and transpar- triage guidelines28 should be reviewed, including ent communication will be key. Paramedics may be triage and monitoring guidelines currently used by wary of using sobering centers if they perceive a existing sobering centers who accept patients from risk of negative patient outcome or concern a triage ambulances. This could include protocols from the error may lead to loss of their license. As noted by San Francisco Sobering Center, Austin Sobering an emergency medical director during the interviews, Center in Texas, and the Los Angeles Fire Department "We know there's a finite error rate [in triage decision- SOBER Unit, which transports to the David L. Murphy making] because humans are humans. It's just going Sobering Center. Second, centers accepting from EMS to happen. . . . We don't get 100% of people going should establish regular reviews of client encounters to the right places the first time. It's just a matter of that arrive via EMS and are later sent to the ED due to training, oversight, quality improvement. That would a medical need. be no different than any other component of the Sobering Centers Explained: An Environmental Scan in California www.chcf.org 23 health care system in terms of where people go and To succeed in the expanded adoption of the sobering then get moved up the food chain if they need to." model of care in California, focused attention should Communication will need to offer both reassurance be given to: and training, while soliciting ongoing feedback from $ Creating low-barrier, accessible services through paramedics and leadership throughout the respective streamlined processes and protocols counties. $ Being responsive to community needs through active engagement with frontline responders Conclusion $ Establishing data management systems for con- sistent, secure collection of client information Nine of the 10 functioning sobering centers of and evaluation California were reviewed, representing 25% of such centers nationwide, through interviews with two dozen $ Collaborating and colocating with related key stakeholders, programmatic document reviews, systems and facilities and site visits. While program details vary, almost all offer services to adults 18 and over, and all but one are There is great variation in the operation, size, and open 24 hours a day, 7 days a week, 365 days a year. models of sobering centers in California, similar to sobering centers nationally. Yet many of the centers Four primary areas of promising practice were identi- have achieved a significant role in serving their com- fied by the interviewees: munities, featuring integrated, well-functioning, and accessible programs for those with acute and chronic $ Operation as a low-barrier, compassionate intoxication. service model $ Development of clear protocols and stream- Sobering centers are a last resort for many people, lined service provision becoming a waystation for those suffering from effects of long-term substance use, related comorbidities, $ Successful, centralized role in care coordination and co-occurring homelessness who have nowhere $ Programmatic flexibility else to go. At its best, a sobering center can serve a critical role in individual patient engagement and care, Significant core challenges to successful center estab- identifying the broad needs of a population at risk of lishment and operation were identified: alcohol- or drug-related harms and providing advo- cacy for high-quality and integrated care and services $ Procurement of initial and ongoing funding within the system. $ Stigma and community acceptance $ Disjointed behavioral health system $ Misunderstanding of sobering care model $ Underutilization by referring parties $ Provisionof care to a population with increasing needs requiring higher levels of service California Health Care Foundation www.chcf.org 24 Appendix. Sobering Center Profiles Bakersfield Recovery Station Bakersfield, Kern County Operating organizations Telecare Inc. partnering with Kern Behavioral Health and Recovery Services Year opened 2020 Operational components Capacity: 10 people Hours: 24 hours a day, 7 days a week Location: 312 Kentucky Street, Bakersfield 93305 Funding mechanism Mental Health Services Act (MHSA) Innovation Funding Oversight Mental Health Services Oversight & Accountability Commission Mission / Target population The goal of the Bakersfield Recovery Station is to provide a law enforcement diversion for persons who are acutely intoxicated and have a co-occurring mental illness where, instead of being arrested, they are presented with an opportunity for peer engagement, assessment, brief clinical interventions, and linkage with community-based services. Admission criteria Intoxication from alcohol and/or any drugs Referring parties Law enforcement, Mobile Evaluation Team (MET), behavioral health treatment providers, homeless providers No walk-ins or self-referrals Staffing model Peer staff trained in mental health and substance use disorder, substance use counselors, project manager, licensed clinician in role as administrator Services provided Mental health screening, assessment, and referrals for care (depression, anxiety, posttraumatic stress disorder); substance use screening; counseling, motivational interviewing; referrals to substance use treatment Proportion of clients served To be determined experiencing homelessness Sobering Centers Explained: An Environmental Scan in California www.chcf.org 25 Cherry Hill Sobering Center San Leandro, Alameda County Operating organization Horizon Services Year opened 2010 Operational components Capacity: 35– 40 people; 17 with social distancing protocols Hours: 24 hours a day, 7 days a week Location: 2035 Fairmont Drive, San Leandro 94578 Funding mechanism Measure A "Essential Health Care Services Initiative," approved in March 2004 Oversight Alameda County Behavioral Health Care Services Mission To deter incarcerating individuals found to be under the influence in the community with the goal of servicing 520–600 clients/month Target population Intoxicated adults throughout Alameda County Admission criteria Intoxication from alcohol and/or any drugs Age 18 and older Referring parties Law enforcement, mental health facilities, emergency department, community organizations, clinics. Walk-ins and self-referrals accepted. Staffing model Registered or certified substance use counselors (intake); certified emergency medical technicians (health technicians); sobering specialists; licensed vocational nurses (weekdays); van driver. Medical direction: On call physician Services provided Food (meals, snacks), oral rehydration, hygiene; direct referral and transfer to medical detoxification. Assist with medication refills. Proportion of clients served Specific data not available for report. Currently serving a large number of individuals who are experiencing homelessness homeless and have high rates of recidivism. California Health Care Foundation www.chcf.org 26 CREDO 47 Stabilization Center Santa Barbara, Santa Barbara County Operating organization Good Samaritan Shelter Year opened 2020 Operational components Capacity: 10 people; 7 with social distancing protocols Hours: 24 hours a day, 7 days a week Location: 427 Camino del Remedio, Santa Barbara 93110 Funding mechanism Proposition 47 Oversight County of Santa Barbara Crisis Services Mission To divert incarceration for substance abuse and connect with treatment opportunities Target population People with substance use disorders Admission criteria Intoxication from alcohol and/or any drugs Referring parties Cottage Hospital, Santa Barbara County Jail, police, sheriff, probation, parole, public defender, child welfare services (adults), family members, walk-ins, crisis services Staffing model EMT paired with sober coaches each shift; certified drug and alcohol counselors, one part- time RN directing medical services, program manager Services provided Food, shelter, medical monitoring, medication management as prescribed, COVID clearances, TB screening. Referrals to mental health and substance abuse services, including medically assisted treatment, housing, and transportation. Legal services and social services. Proportion of clients served Initial utilization data shows 64% of individuals served do not have permanent address. experiencing homelessness Sobering Centers Explained: An Environmental Scan in California www.chcf.org 27 David L. Murphy Sobering Center Los Angeles, Los Angeles County Operating organization Exodus Recovery, Inc. Year opened 2017 Operational components Capacity: 50 people Hours: 24 hours a day, 7 days a week Location: 640 Maple Avenue, Los Angeles 90014 Funding mechanisms Combination including Whole Person Care; Office of Diversion and Re-Entry; Measure H Oversight Los Angeles Department of Health Services, Housing for Health Mission / Target population Divert chronically inebriated vulnerable adults living on or adjacent to Skid Row away from hospitals and institutions including incarceration Admission criteria Intoxication from alcohol and/or any drugs Referring parties Law enforcement, Department of Health Services Outreach Teams, emergency departments, Exodus Outreach, Los Angeles Fire Department SOBER Unit Staffing model Registered nurses, licensed vocational nurses, sober coaches, security officers, recovery supervisor, intake coordinator, program director Services provided Vital sign monitoring, minor wound care, urgent care needs; manage ADLs, hygiene needs, delousing; nutrition and oral fluids; case management for high-use clients; referrals to shelter and detoxification needs; housing and entitlement referrals Proportion of clients served 85% of individuals currently homeless experiencing homelessness California Health Care Foundation www.chcf.org 28 Delano Recovery Station Delano, Kern County Operating organizations Telecare Inc. partnering with Kern Behavioral Health and Recovery Services Year opened 2020 Operational components Capacity: 6 people Hours: 24 hours a day, 7 days a week Location: 629 Main Street, Delano 93215 Funding mechanism Mental Health Services Act (MHSA) Innovation Funding Oversight Mental Health Services Oversight & Accountability Commission Mission / Target population The goal of the Delano Recovery Station is to provide a law enforcement diversion for persons who are acutely intoxicated and have a co-occurring mental illness where, instead of being arrested, they are presented with an opportunity for peer engagement, assessment, brief clinical interventions, and linkage with community-based services. Admission criteria Intoxication from alcohol and/or any drugs Referring parties Law enforcement, Mobile Evaluation Team (MET), behavioral health treatment providers, homeless providers. No walk-ins or self-referrals. Staffing model Peer staff trained in mental health and substance use disorder, substance use counselors, project manager, licensed clinician in role as administrator Services provided Mental health screening, assessment, and referrals for care (depression, anxiety, posttraumatic stress disorder); substance use screening; counseling, motivational interviewing; referrals to substance use treatment Proportion of clients served To be determined experiencing homelessness Sobering Centers Explained: An Environmental Scan in California www.chcf.org 29 First Chance Sobering Station Burlingame, San Mateo County Operating organization StarVista Year opened 1991 Operational components Capacity: 14 people Hours: 24 hours a day, 7 days a week Location: 826 Mahler Road, Burlingame 94010 Funding mechanisms Combination of police departments and county health department Oversight County of Santa Barbara Crisis Services Mission An alternative to jail for those arrested for public intoxication or driving under the influence of alcohol and/or drugs Target population Adults intoxicated in public or under arrest for DUI Admission criteria Intoxication from alcohol and/or any drugs Referring parties Law enforcement, designated hospitals, addiction treatment providers. Walk-ins are not accepted. Staffing model Registered or certified addiction counselors Services provided Oral rehydration and snacks; clean clothing; assessments, case management, coping strate- gies; referrals to treatment services Proportion of clients served Specific data not available for report. experiencing homelessness Note: Interviews were not conducted with leadership or key stakeholders of the First Chance Sobering Station. Details included in this table were obtained via electronic sources through an online search conducted in October/November 2020. California Health Care Foundation www.chcf.org 30 McAlister Institute Sobering Services Center San Diego, San Diego County Operating organization McAlister Institute (since 2015) Year opened 1984 Operational components Capacity: 60 people; 15 with social distancing protocols Hours: 24 hours a day, 7 days a week Location: 3511 India Street, San Diego 92103 Funding mechanisms County of San Diego and City of San Diego Do not bill. Will accept donation (recommended: $35) from participants or family members willing and able to contribute. Oversight San Diego County administrators; McAlister Quality Assurance team Mission Provide county-wide diversion, non-residential, non-medical, sobering services in a drug- and alcohol-free environment for public inebriates and intoxicated individuals dropped off by health, safety, and law enforcement agencies. Target population Adults aged 18 and older contacted by law enforcement under the influence Admission criteria Sobering Services Center: Intoxication related to alcohol and marijuana PLEADS (Prosecution and Law Enforcement Assisted Diversion Services) Pilot program: Intoxication from other drugs including opioids and methamphetamines Referring parties Law enforcement agencies in San Diego county Staffing model Service navigators, substance use disorder counselors, registered alcohol and drug techni- cians; registered nurses (12 hours/ day specific for PLEADS pilot program), program director, medical director (administrative) Services provided Laundry, bathroom, clean clothing, storage of personal belongings (up to 72 hours), minor wound care, light food and oral rehydration. Counseling, resource information, and referrals to stabilizing services including treatment, shelter, and housing resources. Community collabora- tions provide Medically Assisted Treatment (MAT) and short-term psychiatric care. Proportion of clients served 10% unduplicated clients are chronically homeless experiencing homelessness Sobering Centers Explained: An Environmental Scan in California www.chcf.org 31 Mission Street Sobering Center San Jose, Santa Clara County Operating organization Horizon Services, Inc. Year opened 2017 Operational components Capacity: 20 people total (10 Sobering, 10 Mental Health Drug Triage pilot project); 10 with social distancing protocols Hours: 24 hours a day, 7 days a week Location: 151 W Mission Street, San Jose 95110 Funding mechanism Whole Person Care Oversight Whole Person Care administrators; leadership within County of Santa Clara including from ReEntry Resource Center, EMS Agency, Substance Use Treatment Services Mission / Target population Reduce the use of hospital emergency rooms and jails in the care of acute intoxication Admission criteria Sobering: Alcohol only Mental Health Drug Triage pilot: Methamphetamines, marijuana Referring parties All Santa Clara County law enforcement agencies; Santa Clara County operated EDs (Valley Medical, O'Connor, and Saint Louise); and county community organizations who provide substance use and mental health treatment services Staffing model Licensed vocational nurses, EMTs, sobering specialists Services provided Crisis Intervention, medical and mental health assessment, motivational interviewing, HMIS – VISPDAT assessments for housing, Medi-Cal applications, care coordination with Whole Person Care and case managers, clothing, showers, light stacks, referrals, transportation to and from providers. Proportion of clients served 41% clients currently homeless experiencing homelessness California Health Care Foundation www.chcf.org 32 San Francisco Sobering Center San Francisco City and County Operating organizations SF Department of Public Health partnering with Community Forward SF Year opened 2003 Operational components Capacity: 12 people; 5–6 with social distancing protocols Hours: 24 hours a day, 7 days a week Location: 1185 Mission Street, San Francisco 94103 Funding mechanisms City and County of San Francisco General Fund Oversight Department of Public Health, City and County of San Francisco Mission Providing safe, short-term sobering and care coordination for actively intoxicated adults as an alternative to the emergency department and jail Target population Individuals with co-occurring homelessness and alcohol use disorder Admission criteria Primary focus: alcohol intoxication. Other drug intoxication accepted based on individual behavior to ensure safety for clients and staff. Referring parties Field paramedics, police, sheriff, emergency departments, community paramedics, physical and mental health clinics, community agencies. Walk-ins on limited basis for case managed clients. Staffing model Registered nurse (24 hours a day), personal care assistants/ certified nursing assistants, peer navigator, social worker, part-time nurse practitioner, charge nurse, program director Services provided Vital sign monitoring, minor wound care, urgent care needs; manage ADLs, hygiene needs, delousing; nutrition and oral fluids; case management for high-use clients; referrals to shelter and detoxification needs; withdrawal management to bridge to detoxification services; medication management Proportion of clients served 60–70% of unduplicated individuals served are currently homeless. experiencing homelessness >95% of returning clients have current or former history of homelessness. Sobering Centers Explained: An Environmental Scan in California www.chcf.org 33 Sun Street Centers Sobering Center Salinas, Monterey County Operating organizations Sun Street Centers partnered with Monterey County Behavioral Health Department Year opened 2017 Operational components Capacity: 10 people Hours: Thursday at 3pm through Monday at 3:30pm Location: 119 Capital Street, Salinas 93901 Funding mechanisms Proposition 47 Grant with Monterey County Behavioral Health Department Monthly "Whole Person Care" billing Oversight Monterey County Behavioral Health Department Mission Preventing alcohol and drug addiction by offering education, prevention, treatment and recovery to individuals and families regardless of income level. Target population All individuals 18 years and older with public intoxication (penal code 647F) or driving under the influence (DUI) Admission criteria Accept drug intoxication if alcohol is also present. Additional assessments completed on individuals under influence of opiates or methamphetamines to ensure safe for sobering environment. Referring parties Law enforcement including but not limited to police, sheriff, and California Highway Patrol Staffing model Recovery specialists, medical assistants, program manager, data entry person Services provided Assess and monitor BAC via breathalyzer. Vital signs, assess for withdrawal, provision of light food and oral rehydration. Referrals to physical, mental health, and substance use services. Transportation provided upon discharge. Proportion of clients served Specific data not available for report. experiencing homelessness California Health Care Foundation www.chcf.org 34 Endnotes 1.Emmeline Chuang et al., "Integrating Health and Human 13.James V. Dunford et al., "Impact of the San Diego Serial Services in California's Whole Person Care Medicaid 1115 Inebriate Program on Use of Emergency Medical Resources," Waiver Demonstration," Health Affairs 39, no. 4 (Apr. 2020): Annals of Emergency Medicine 47, no. 4 (Apr. 1, 2006): 639– 48. 328–36; Otis Warren et al., "Identification and Practice Patterns of Sobering Centers in the United States," 2."Board Awards $103m in Prop 47 Funds to Innovative Journal of Health Care for the Poor and Underserved Rehabilitative Programs," California Board of State and 27, no. 4 (Nov. 2016): 1843–57; Suzanne V. Jarvis et al., Community Corrections, June 8, 2017. "Public Intoxication: Sobering Centers as an Alternative 3.Janet M. Coffman et al., "Evaluation of California's to Incarceration, Houston, 2010–2017," Amer. Journal of Community Paramedicine Pilot Program," Healthforce Center Public Health 109, no. 4 (Apr. 1, 2019): 597–99; Shannon at UCSF, February 19, 2021. Smith-Bernardin et al., "Utilization of a Sobering Center for Acute Alcohol Intoxication," Academic Emergency Medicine AB 1544 (Cal. 2019). 4. 24, no. 9 (Sept. 2017): 1060–71; Shannon Smith-Bernardin, 5."Alcoholism and Intoxication Treatment Act," Uniform Law "Changing the Care Environment for Acute Intoxication: Commission. Providing Intoxicated Adults an Alternative to the Emergency Department and Jail. Revise-Resubmit," Journal of Studies of 6.Wendy Holt, 2018 Edition - Substance Use in California: Alcohol and Drugs, Supplement 2020; and Smith-Bernardin, A Look at Addiction and Treatment, California Health Care Kennel, and Yeh, "EMS Can Safely Transport." Foundation (CHCF), October 3, 2018. 14.Warren et al., "Identification and Practice Patterns"; and 7."Position Statement 33: Substance Use Disorders," Mental Smith-Bernardin, "Changing the Care Environment." 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Cornwall et al., "A Pilot Study of Emergency Medical Technicians' Field Assessment of Intoxicated Patients' Need for ED Care," Amer. Journal of Emergency Medicine 30, no. 7 (Sept. 2012): 1224–28. Sobering Centers Explained: An Environmental Scan in California www.chcf.org 35 24.August F. Holtyn et al., "An Intensive Assessment of Alcohol Use and Emergency Department Utilization in Homeless Alcohol-Dependent Adults," Drug and Alcohol Dependence 178 (Sept. 1, 2017): 28–31; David A. Pearson, Amanda R. Bruggman, and Jason S. Haukoos, "Out-of-Hospital and Emergency Department Utilization by Adult Homeless Patients," Annals of Emergency Medicine 50, no. 6 (Dec. 1, 2007): 646–52; Thomas P. O'Toole et al., "Factors Identifying High-Frequency and Low-Frequency Health Service Utilization Among Substance-Using Adults," Journal of Substance Abuse Treatment 33, no. 1 (July 1, 2007): 51–59; and Anna Burak, Katarzyna Cierzniakowska, and Aleksandra Popow, "Homeless People Under the Influence of Alcohol Admitted to Hospital Emergency Departments in Poland," Nordic Studies on Alcohol and Drugs 37, no. 2 (Apr. 1, 2020): 190–200. 25.Kristen Paquette, Current Statistics on the Prevalence and Characteristics of People Experiencing Homelessness in the United States, SAMHSA, last updated July 2011; and "Substance Abuse and Homelessness," National Coalition for the Homeless, July 2009. 26.Mary E. Larimer et al., "Health Care and Public Service Use and Costs Before and After Provision of Housing for Chronically Homeless Persons with Severe Alcohol Problems," JAMA 301, no. 13 (Apr. 1, 2009): 1349–57; Douglas L. 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