Division of Citywide Case Management Programs

982 Mission St., San Francisco, CA 94103
Phone: (415) 597-8000
Fax: (415) 597-8004

Division Director: Fumi Mitsuishi, MD, MS
Division Administrator: Constance Revore, MSSW, MBA

Since 1981, the Division of Citywide Case Management Programs has operated under the direction of the Department of Psychiatry at Zuckerberg San Francisco General Hospital and Trauma Center. Its mission is to support the recovery of San Francisco’s highest risk mentally ill adults and to reduce their use of institutional and acute care (psychiatric emergency services, hospital care, and/or jails), while helping to maximize their ability to maintain stable, productive, fulfilling lives in the community. All division program services include medication assessment and management, crisis intervention, outreach and case management, and individual, group and family therapy, which continue as long as clients need an intensive level of intervention. The division consists of the following programs:

Citywide Focus

Program Director: Bonnie Schwartz, LCSW

Serves 400 of the highest consumers of San Francisco Community Behavioral Health Services (CBHS) acute services with four culturally-focused Assertive Community Treatment (ACT) model teams:

Cross Currents Team (LGBTQ and women): Program Director: Bonnie Schwartz, LCSW
Kujichagulia Team (African-American and European-American): Program Director: Denise Corbin, LCSW 
Senderos Team (Latino and Korean): Program Director: Debra Wyman-Dixson, LCSW 

Citywide Forensics

Program Director: Kathleen Lacey-Connolly, LCSW

Serves 150 adults referred from the San Francisco Behavioral Health Court (BHC) partners. Clients suffer from serious mental illness, made more complicated with substance abuse and have long histories of felony level criminal justice involvement. The goal of the BHC is to engage clients in treatment under court supervision, as a way to resolve current criminal charges, reduce the likelihood for recidivism, and improve mental health outcomes.

Citywide Linkage Team (CLT)

Program Director: Ho Yan Nip, ASW

Provides two-to-four month comprehensive clinical and case management services to clients being discharged from psychiatric inpatient hospitals to the community. At any given time, approximately 75 clients are being served by this team. CLT has been critical in helping to reduce the length of inpatient stay at Zuckerberg San Francisco General, and thus minimize Medi-Cal decertified bed days.

Citywide Roving Team

Program Director: Eric Brown, MFT

  • Roving Team: Works with residents of 26 service supported hotels with 2,446 units managed through the Human Services Agency.
  • Drs. Julian and Raye Richardson Apartments: Opened in September 2011, managed by SFDPH/Direct Access to Housing (DAH).  The building is located in Hayes Valley and has 120 units; it houses formerly homeless persons with chronic medical and psychiatric conditions.  The building is staffed by a multidisciplinary team providing case management services, crisis intervention, outreach, medication management and monitoring.
  • Rene Cazanave Apartments: Opened in late 2013, the building is also managed by DAH.  It is located close to the Transbay terminal, and staffed in a similar way to the Richardson.

Citywide Employment Services

Program Director: Gregory Jarisitis, MOT, OTR/L

Serves clients across the division and/or living in San Francisco interested in employment training.  Here are some of their programs:

  • Cooperative Partner to San Francisco Department of Rehabilitation: Serving any consumer of mental health services in San Francisco interested in employment services.  Specializes in working with persons with a criminal justice history or with pending legal charge.  Total service capacity is 170 clients.
  • Stipend volunteer-based vocational training at Zuckerberg San Francisco General: Provides an opportunity for social enterprise and vocational training.
  • First Impressions: In partnership with the Asian Neighborhood Design, clients receive training in basic construction and remodeling skills, and participate in remodeling project of SFDPH/Community Behavioral Health Services (CBHS) clinics’ waiting room, with aim to make them more welcoming and culturally representative of the clients served.
  • Housing and Employment for Recovery Outcomes (HERO): For clients participating in the Behavioral Health Court, this program provides six months of no-cost housing and supported employment, with the idea that employment is the primary treatment goal.

Citywide Substance Treatment Outpatient Program (STOP)

Program Director: Valerie Gruber, PhD

STOP provides outpatient substance use disorders treatment to adults who have co-occurring psychiatric conditions, chronic illness, or criminal justice involvement.

San Francisco residents with Medi-Cal or no insurance may be referred by designated staff in each setting where STOP is integrated:

  • UCSF Citywide Case Management (982 Mission Street): Certified outpatient addiction treatment program for Citywide Case Management clients
  • San Francisco Sobering Center: Intensive case management for high utilizers of the Sobering Center and other acute services
  • Adult Probation Department, Community Assessment and Services Center (CASC): Substance use services within mental health program for clients on probation in San Francisco county
  • UCSF Positive Health Program at Zuckerberg San Francisco General​ (a primary care clinic): Individual and couples integrated substance use/mental health counseling for Positive Health Program clients

STOP clinicians help participants clarify their needs and goals using motivational interventions, and guide them in behavior change (i.e. harm reduction, cessation of use, or relapse prevention, using evidence-based, trauma-informed, culturally-attuned approaches). Participants receive one or more of the following services depending on their needs and site capacity:

  • Assessment and treatment planning
  • Group counseling (at 982 Mission St., CASC)
  • Individual counseling
  • Couples or other collateral sessions
  • Coordination with clinicians who prescribe medications for addiction
  • Referrals and service coordination

Emergency Department Case Management Program (EDCM)

Program Director: Giselle Clark-Ibanez, LCSW

Emergency Department Case Management (EDCM), based at Zuckerberg San Francisco General, is an intensive clinical case management program that facilitates psychosocial, medical, and psychiatric care by establishing therapeutic relationships with individuals who experience complex medical and behavioral health problems and frequently rely on acute care services. Our interdisciplinary team works to improve health and well-being for our patients and to support the appropriate utilization of limited publicly funded services in San Francisco.

Eligibility requirements:

  • In past 12 months, five or more visits to the Zuckerberg San Francisco General Medical Emergency Room OR three or more medical admits to Zuckerberg San Francisco General OR identification as a top 1% high utilizer of multiple services (HUMS)
  • Not currently receiving duplicate services
  • Voluntarily participate in services
  • At least 18 years of age
  • San Francisco resident
  • In need of intensive case management
  • A psychiatric diagnosis is not required

Program resources

The division has developed numerous unique resources aimed at providing evidenced-based treatment for the enormous challenges faced by our clients:

  • The largest SFDPH/CBHS Dialectical Behavioral Therapy (DBT) group.  DBT is an evidenced-based treatment for high-risk, self-injurious consumers, especially those suffering from borderline personality disorder.  It has been shown to reduce emergency visits, volatile behaviors, and increase affective control.
  • On-site payee and budgeting services for over 250 consumers, including daily disbursement. These services reduce homelessness and increase the client’s ability to provide adequate clothing and shelter while improving planning and self-care skills.
  • Culturally-focused services: Services are rendered in the client’s language of origin by clinicians who are bi-cultural.  They are often delivered in the community using natural supports.  A committee of line staff and consumer reviews the cultural functioning of the center, develops mandatory training, recommends policy changes, and puts together an annual cultural competency plan.  We have capability in Spanish, Tagalog, Russian, Korean, Farsi, French and four Chinese dialects.

Research collaboration

In addition to providing evidenced-based treatment, Citywide Case Management Programs is committed to helping develop and document innovative and effective interventions. The division’s strong long-term engagement with high-risk clients and comprehensive intervention strategies enables us to effectively partner with UCSF and outside institution researchers to improve outcomes for this typically hard-to-reach population.

Research topics thus far include:

  • Study of older adults with schizophrenia, health issues and connectedness to case managers
  • Food insecurity among adults suffering severe mental illness
  • Promoting physical activity with seniors suffering severe mental illness and with young adults with severe mental illness
  • Effect of Mental Health Courts on arrests and jail days
  • Effects of substance dependence on outcomes of patients in a randomized trial of two case management models
  • Outcomes of California Mentally Ill Offender Crime Reduction program
  • Neuroplasticity-based cognitive remediation on employment activity outcomes in persons with schizophrenia

Core faculty