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SLO County came together to fight COVID. Can it do the same for mental health care crisis?

Tribune - 10/29/2022

Oct. 29—During the early days of the COVID-19 pandemic, healthcare leaders at local hospitals and in San Luis Obispo County government came together to ensure the community was prepared to respond to the encroaching threat of a deadly virus.

Nearly three years later, the coronavirus is mostly under control, but now San Luis Obispo County is facing a not-so-new health crisis, one that has been building in the shadows for decades — the increasing prevalence of mental health emergencies and their impact on hospitals.

"I think behavioral health is every bit as dangerous — it's more dangerous than the COVID pandemic," Tenet Health Central Coast CEO Mark Lisa said.

Dignity Health Hospital Administrator Ken Dalebout echoed Lisa's concerns.

"Ten years ago, (Arroyo Grande Community Hospital) would have one to three psychiatric patients a week. ... The census in Arroyo Grande in the ER now is one to two a day," Dalebout said. "Ten years ago, it was a problem. Now it's a crisis."

Despite concerns from local healthcare leadership, behavioral health services in San Luis Obispo County remain under-resourced — particularly for patients requiring a higher level of psychiatric care.

Many must leave the area for treatment because the county has no comprehensive inpatient psychiatric facility. But even before that step, local residents in crisis suffer shortages of care for even their most immediate psychiatric needs.

Since San Luis Obispo County General Hospital closed in 2003, the county has relied on a patchwork of local emergency rooms and the county-run Psychiatric Health Facility to handle mental health emergencies. The PHF has 16 acute inpatient beds, but access is limited to locals placed on mental health holds who are deemed indigent, are incarcerated or use Medi-Cal.

Those restrictions mean many SLO County residents experiencing a mental health crisis are ineligible to be treated at the only local acute psychiatric facility in the community.

"There's not enough beds in our county. There's not enough beds in the state," San Luis Obispo County Administrator Wade Horton said. "It's an extreme challenge when we have an individual that's in a psychiatric crisis — an ER bed is not the best place for them."

The shortage of psychiatric beds means that when an individual comes to the hospital in a mental health crisis, they can sometimes spend days waiting in the emergency department until a bed frees up at a psychiatric hospital somewhere else in California.

The typical emergency room patient is in the hospital for roughly two to four hours, Dalebout said. Comparatively, psychiatric patients spend on average more than 24 hours in the emergency department waiting for transfer to a specialized facility.

"It doesn't fit the care model, necessarily, when you have a patient there for multiple days," Dalebout said of boarding psychiatric patients in the emergency room.

The boarding of psychiatric patients in local emergency departments puts a strain on patients, doctors and hospital resources. A July 2022 report by the San Luis Obispo County grand jury held Behavioral Health responsible for the overflow of psychiatric patients in county emergency departments, a criticism the agency rejects.

"As a community, we want to do more," Horton said.

SLO County Behavioral Health, private hospitals have historically failed to unite

The grand jury report pointed to numerous shortcomings on the part of county Behavioral Health when it came to caring for mentally ill residents in San Luis Obispo County, such as the influx of mental health patients in local emergency rooms, the absence of psychiatric beds for youth and seniors and an overall failure of leadership.

In a September rebuttal to the report, county Behavioral Health Director Anne Robin said that wait times in SLO County are not uniquely long compared to California as a whole. The boarding of psychiatric patients in emergency departments statewide averages 30 hours, while in SLO County the average wait time for transfer to a psychiatric hospital is 24 to 30 hours, Robin said.

"On paper, there appears to be a wealth of resources being applied to the challenges associated with providing services to people on holds within our county," the grand jury report says. "In practice, however, those services appear to be out of reach for many of our most at-risk residents."

Robin told the Tribune in August that the grand jury failed to understand the county's limited mandate, which is to provide care for Medi-Cal recipients, the indigent or incarcerated. Anyone with private insurance who experiences a mental health crisis is outside the scope of Behavioral Health.

In her rebuttal to the grand jury, Robin pushed back against hospitals, saying that private facilities have failed to uphold their obligations under the Emergency Treatment and Labor Act (EMTALA), which requires that hospitals arrange and pay for transport for patients whose medical needs cannot be served by their facilities.

"The hospitals depend on the county to provide care for individuals in psychiatric distress, not the inverse as stated in this finding," Robin wrote. "The county has gone above and beyond its legal obligations to support patients in this area and will continue to encourage all local entities to fulfill their related responsibilities, for the benefit of patients and our community as a whole."

Local mental health advocates who have been privy to conversations between private hospitals and the county said the finger-pointing between the hospitals and the agency is not overly surprising — for decades, local healthcare stakeholders have been unwilling to take responsibility for filling the gaps in mental health services locally.

"We talk a lot about mental health in this county, but nothing ever happens," Lisa said.

The longtime lack of political will to invest in behavioral health services is not a problem unique to SLO County.

Dalebout recalled a meeting at Marian Regional Medical Center in Santa Maria between hospital owner Dignity Health and Santa Barbara County that occurred about a decade ago with the goal to find a solution to help local psychiatric patients that come to Marian.

"It was the longest and most quiet hourlong meeting I've ever been to, because no one said anything," Dalebout said. "I mean, there was some talk. In the end of it ... everybody was waiting for somebody else."

Lisa reflected on the differences between the collaborative COVID-19 response and the lack of leadership around building a stronger set of mental health services for acute patients.

"Why aren't we feeling that same sense of urgency and community civility to approach (behavioral health), which is more dangerous than what we were facing in April of 2020?" he asked.

When California needed beds during COVID-19, SLO County built them

An example of how health leaders responded to the need for local beds during the COVID-19 pandemic versus the chronic shortfall of psychiatric beds shows how behavioral health has historically not received the level of priority that the problem warrants.

In March 2020 the state announced it needed an estimated 50,000 extra hospital beds ready to treat potential waves of COVID-19 patients.

But health stakeholders across SLO County were ahead of schedule.

Together, they stood up 1,000 extra beds to treat coronavirus patients at a makeshift hospital at the Cal Poly Rec Center about a month after the pandemic reached the United States. The alternate care site cost about $3.5 million and was there in case local intensive care units were overrun.

"We have been aggressively moving forward on this issue," Horton, who also acts as county emergency response director, said at a 2020 news conference about the makeshift hospital. "We have not waited for the governor. We have not waited on the federal government. We have leaned way forward on this."

As it turned out, local hospitals were able to manage the influx of COVID patients, so the makeshift hospital was never needed. It closed in April 2021.

But the effort was a good example of how leaders collaborated around a common cause — and produced meaningful results quickly.

Comparatively, the state of California has an existing shortfall of roughly 4,767 psychiatric beds in acute and sub-acute care settings and a shortage of 2,963 community residential beds, according to a report from the RAND Corp. Communities of about 100,000 residents, roughly a third the size of San Luis Obispo County, need about 50 psychiatric beds to serve local needs, the report said.

That means SLO County should have close to 150 mental health beds to properly serve its population of 282,000 people.

Instead, all it has are the 16 acute psychiatric beds at the PHF for adult Medi-Cal and indigent patients, no sub-acute psychiatric beds and no beds for adults with private insurance, or pediatric or senior psychiatric patients.

People who work in healthcare are quick to point out that the shortage of psychiatric beds is a problem endemic across California. In her response to the grand jury report, Robin attached the RAND report that describes the lack of psychiatric beds throughout the state.

Many health leaders argue that establishing more psychiatric beds locally is the responsibility of the state or requires state funding.

It's a stark contrast to the sentiment expressed by county leadership during the COVID-19 pandemic, though more funding was available to support building healthcare infrastructure for the coronavirus than historically has been available for behavioral health.

"During the pandemic, nobody said, 'Well, this is a governance issue' or 'It's a private (issue).' Everybody said, 'This is all our issue. We better do something about it,'" Lisa said. "And that first month or two of the pandemic was almost fun in the sense that we pulled together in a crisis. We were the old America again. We put aside our political pettiness, our differences. And it didn't matter who the hospital owners were or who was in charge. ... we just came together, said, 'This is what we got to do.'"

How Behavioral Health gets on the county leadership's radar

After decades of inaction on mental health care, the political winds may finally be shifting.

Shortly after The Tribune ran two articles in September about Paso Robles resident Kimberlee Booth's attempts to secure long-term care through Behavioral Health for her 22-year-old daughter, who is homeless and vulnerable due to her schizophrenia, county leadership began to take a closer look at the gaps in behavioral health services in SLO County.

Nick Drews was appointed as the interim agency health director in June, a role that oversees the county's Behavioral Health Department.

Drews reached out to Booth to hear her story firsthand and has been in conversation with local hospitals about how to improve services for community members with severe mental illness.

"I think Nick's been attentive. He's been keeping in touch and doing a good job," Lisa, the local Tenet CEO, said. "I think there's a lot more awareness by all around."

Horton said the Board of Supervisors is also starting to focus more on how to develop solutions to the behavioral health crisis in SLO County.

"There's certainly political will from the Board of Supervisors to address this issue, but there's a lot of challenges we're having right now," Horton said.

The biggest one? Money.

"We do need to think outside the box and look for other opportunities to provide additional services, but you have to have funding available too. So that's the challenge," Horton said. "And that's where I'm looking forward to working with Tenet and Dignity to figure out how we can leverage our collective resources."

SLO County's existing unlocked Crisis Stabilization Unit is underused

One service SLO County is taking a closer look at is the existing, county-run Crisis Stabilization Unit. The goal of the facility is to help patients in crisis stabilize and avoid hospitalization, but its not working as effectively as it could.

The facility is an unlocked residential care facility with capacity for up to four patients in crisis for up to 24 hours. Patients check into the CSU voluntarily and leave voluntarily. It is staffed by Sierra Mental Wellness Group.

The Crisis Stabilization Unit is an underutilized resource, according to the 2022 grand jury report. Typically one person per day visits the CSU, with an average of 45 monthly patients. The unit can treat up to 120 patients per month, the report said.

"If you look at our census, are we maximizing the use of that facility?" Horton said. "I believe that there's an opportunity to do more."

The unlocked CSU, however, is a mismatch for SLO County's needs for services for acute patients.

"The CSU in SLO County doesn't match the acuity of the ER patients. And so it's not an option for the ER. It's an option for some other groups, but if you were to stand up and say, 'That's our solution to help the hospitals' ER problem, it's not gonna work," Dalebout said.

Community members that are placed on mental health hold and sent to the hospital for medical clearance require services at a locked facility to prevent elopement before the hold has lapsed.

"If a client exhibiting potentially threatening behavior decides to depart the CSU, written policy directs staff to allow the client to depart and, if warranted, to call 911 to request law enforcement response for assistance," according to the 2022 grand jury report. "In practice, however, the grand jury heard interview testimony that it was not uncommon for a CSU staff member to follow such clients onto the street and keep them under observation until law enforcement arrived."

How Dignity Health responded in Santa Barbara County

While SLO County has been slow to act on behavioral health needs, one county over, Dignity Health Southern California leaders decided to move forward on a hospital-based solution to reroute patients placed on mental health holds from the emergency department to a more therapeutic setting.

"In this part of Santa Barbara County, Dignity Health said, 'We're tired of waiting. We're just gonna do it ourselves,'" Dalebout said. "And we're gonna figure out how to get paid for it."

Traditionally, behavioral health services were seen as county-led enterprises. At first, leadership within Santa Barbara County government was reticent about the idea of a private hospital opening a psychiatric unit that serves Medi-Cal psychiatric patients, Dalebout said.

"The people that are in place now are like, 'This is awesome' and are very, very supportive. The others were like, 'Why would a private organization do that? That's always been a county responsibility," he said.

The philosophical tension between the county and Dignity Health dissipated after new county leadership stepped in, he said. But the idea of a hospital-run psychiatric facility that accepts Medi-Cal patients that would normally be served by the county required a shift in perspective.

"I may be different than my colleagues on this — the county's mandate is to take care of the Medi-Cal population," Dalebout said. "I have a feeling with some that it's like 'No, no, no, they're responsible for all mental health patients.'"

"No." Dalebout continued. "They're responsible for Medi-Cal patients."

Santa Barbara County and Dignity Health came to an agreement that the county will reimburse Dignity Health for serving Medi-Cal psychiatric patients through the new facility instead of leaving the care of these payers up to the Santa Barbara County health agency, he said.

Inside Marian's new locked outpatient psychiatric facility

In September 2022, after more than a year of bureaucratic hurdles, Dalebout opened what's called a Lanterman-Petris Short (LPS)-designated outpatient psychiatric facility at Marian hospital in Santa Maria.

The Lanterman-Petris Short (LPS) Act was passed in California in 1967 and ended involuntary and indefinite confinement of mental health patients to hospitals.

The designation means the mental health facility is licensed by the county, according to the act. These types of facilities are frequently locked and used for temporary involuntary commitments for the duration of a patient's mental health hold. Types of LPS-designated facilities include licensed psychiatric hospitals, licensed psychiatric health facilities and certified crisis stabilization units, according to the act.

The facility at Marian moves psychiatric patients on mental health holds who are medically cleared by emergency physicians out of the chaos of the emergency department into a more therapeutic setting, Dalebout said.

The outpatient psychiatric facility at Marian is locked and patients can stay for a maximum of 23 hours and 59 minutes per the governing regulation or until they are stabilized based on a psychiatrist's assessment.

"As a hospital operator, if my problem is patients backing up my emergency department, then I need some place that can take that level of patient," Dalebout said. "So I need a crisis stabilization unit or an EmPATH unit that has the same level of security as the ED. It's almost always got to be locked."

The goal of the facility was to free up valuable bed space in the emergency department and help psychiatric patients stabilize and hopefully avoid hospitalization at an acute inpatient psychiatric facility, he said.

The facility features comfortable reclining chairs, a television set, tables, laundry machines and more to help patients decompress from their emergency room stay for the duration of their hold.

There are also two private rooms with beds for patients who might want a quiet moment. The beds can be equipped with restraints if a patient is displaying violence toward themselves or others, though this is an uncommon occurrence in this type of unit, Dalebout said.

The facility has psychiatry services for eight hours a day and at least one nurse and a second licensed person — either a nurse or a psychiatric technician — on duty at all times so that the facility can accept patients from the emergency room 24 hours a day, seven days a week.

Construction on the outpatient psychiatric unit cost about $1.5 million, Dalebout said. If the hospital built out a hospital-based inpatient psychiatric unit, it would have cost about $2 million per bed to build and would have served many acute patients from outside the Central Coast.

The outpatient psychiatric unit was not built as a money-making endeavor for Dignity Health, Dalebout said. At best, it will help them avoid losses at the emergency department and possibly break even.

"We're just very fortunate that we have the team here at Marian (and) Arroyo Grande that saw the need, because this is not going to make money. This is not building a new surgical program where we're gonna make a ton of money doing it," he said. "I am proud of the organization — this is a community-need driven (program)."

From its opening day on Sept. 7 through Oct. 7, 41 patients were transferred from the emergency department to the outpatient psychiatric unit, Dalebout said.

Of those patients, 19 were stable enough to be discharged home, 10 went to an inpatient care facility for more acute treatment, and the remaining three went to an intermediate care facility like sober living or a group home.

"There's room for improvement, and we're getting better," he said "We're reducing the number of inpatient transfers needed for these patients."

Could SLO County open a hospital-based unit similar to Marian?

San Luis Obispo County hospital and county administrators said they are taking a fresh look at how Behavioral Health operates in San Luis Obispo County, including how to improve front-line services.

The outpatient psychiatric facility at Marian hospital piqued the interest of SLO County stakeholders.

"I really commend Dignity for what they're able to do, and it's certainly a concept that I'm interested in looking to implement here for our county," Horton said. "We're at the very, very beginning of discussions about it."

The prospect of opening an outpatient psychiatric unit, possibly in the form of a hospital-based crisis stabilization unit, is not a new idea in San Luis Obispo County.

In August 2021, the healthcare consulting firm Vituity conducted a study into the feasibility of opening an urgent care model for psychiatric treatment in SLO County. The study was commissioned by Transitions Mental Health Association (TMHA) and shared with The Tribune.

Vituity found San Luis Obispo County could benefit from opening a hospital-based crisis stabilization unit, also called an EmPATH unit, which is essentially the same as what Dalebout built at Marian Hospital in Santa Maria.

Scott Zeller, who authored the study, said SLO County could set-up a functional EmPATH unit quickly, if there is political will at the county level.

"I think that's the important part — the county. If the county supports it, and then there's willing people like Mark Lisa, then it could go forward really quickly," Zeller told the Tribune in an August interview.

Lisa said Tenet Health's 2023 business plan includes a request for funding to conduct a study to see if it's feasible for Tenet Health to stand up a four-seat outpatient psychiatric unit at Twin Cities Community Hospital in Templeton, modeled similarly to the one created at Marian.

Dalebout and Zeller explained that licensing a hospital-based psychiatric facility at Marian was complicated. Bureaucratic hurdles around licensing delayed Marian from opening the facility for 18 months, even though it was staffed and ready much earlier.

Despite the delays, Dalebout created a path forward for future hospital-based outpatient psychiatric facilities to be licensed by the California Department of Public Health, which licenses hospital-based facilities.

"Let me give public kudos to Ken because he did break ground and he has tenacity and perseverance. So he should get some accolades for doing that on behalf of everybody," Lisa said.

What's next for Behavioral Health in SLO County?

An informal public-private partnership of healthcare stakeholders in San Luis Obispo County, including Tenet Health, Transitions Mental Health Association (TMHA), Dignity Health and county leadership, has been meeting to discuss the future of behavioral health locally.

An external consulting group was recently hired to analyze the gaps in behavioral health services in San Luis Obispo County, TMHA director Jill Bolster-White said.

A lot of people who have worked in mental health and homelessness services in San Luis Obispo County have anecdotal evidence to support the need for various services, from psychiatric beds for youth and seniors to a hospital-based crisis stabilization unit to a full-service inpatient facility that would prevent local residents from having to leave SLO County for critical care.

The gap analysis will take a more objective, data-driven look at what solutions are most feasible and most urgent for the community and answer the pertinent questions: "What do we need in this community? What's the right size? What's the right scope?" she said.

Also, because TMHA is the organization that is working with the behavioral health consulting group, there's an opportunity for collaboration across public and private sectors, she said.

"I am trying to come up with ways that we can do this analysis and have it meaningfully inform the conversation about what our strategic plan is as a county for behavioral health services," Bolster-White said.

County leadership and health stakeholders are beginning to take a deeper look at the systemic challenges surrounding behavioral health services in SLO County. But for meaningful changes to occur, there must be a common goal, cooperation across agencies and organizations, and above all, buy-in from county government.

"We need to have a collective community psyche that we need to do this, that this is bad, this is real," Lisa said. "And we need to not worry about politics. We need to not worry about taxes. We need to not worry about all the other myriad issues that we have in our day-to-day lives. If we're going to take this seriously and do something about it, then we need to have a bias for action."

This story was originally published October 27, 20225:30 AM.

CORRECTION: The original version of the article misspelled Ken Dalebout's last name. The mistake has been corrected.

Corrected Oct 29, 2022

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