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Is SLO County mental health system failing residents? Here's what grand jury report says
Tribune - 8/3/2022
Aug. 3—A San Luis Obispo County civil grand jury report found significant failings in the ways county agencies provide mental health care for community members — particularly when it comes to treatment of people on psychiatric holds and the availability of services for youth.
The grand jury report also highlighted a workforce shortage that's causing delays in treatment.
"SLO County fails to provide the kind of unified, integrated and 'single' voice leadership" needed to (deliver) mental health services in a manner that meets the needs of our community while simultaneously respecting and appropriately protecting the professionals who strive to provide such services," the 2021-22 grand jury wrote in the report, released on July 26.
Anne Robin, director of the San Luis Obispo County Behavioral Health Department, acknowledged there continue to be gaps in the local mental health system — particularly in regard to staffing at the agency and a lack of inpatient psychiatric services for children and the elderly.
The foreman of the 2021-22 grand jury, George Tracy, said the investigators discovered significant discrepancies between agency policies and practices.
"What we found, as the report states, is there are things that go on that doesn't really match what the county says that they're doing," Tracy said.
However, the jurors did not recognize limitations and responsibilities the agency faces when it comes to delivering mental health services, Robin said.
"I understand why the grand jury may hear very impassioned voices and hear that versus looking at the very dry law and regulatory issues," Robin told The Tribune.
Robin said the agency is working to identify and implement solutions to help bridge the gaps that leave many residents with severe mental illness vulnerable.
External factors such as affordable housing, caps on the length of inpatient hospital stays and other factors that are beyond that the agency's control can contribute to mentally ill community members cycling through the justice and social services systems, she said.
"Our responsibility, as the mental health plan for MediCal, is to pay for medically necessary inpatient services for MediCal beneficiaries of SLO County," Robin said. "We are not mandated to provide all of them."
What did grand jury look at?
The 2021-22 grand jury, which consisted of 15 to 19 people at a time, conducted its investigation from the beginning of 2021 through June 2022.
Jurors interviewed 16 people involved with mental health services in the county, such as doctors, nurses, hospital executives, county executives, unit supervisors and managers, security officers and psychiatric care specialists.
Jurors also reviewed documents, videos and photos of incidents, past grand jury reports, news articles and written correspondence, among other items.
"It's a good report and I think people should spend some time reading about what's happening in the county for people who have real serious mental health issues," Tracy said.
The mother of a SLO County resident who's living with severe mental illness questioned Behavioral Health's will to improve availability and access to vital mental health services.
"We need to tell the community that what you hear from Anne Robin and what we're getting don't match," Dawn Marie Anderson, of Los Osos, said.
Anderson's son, Chris Anderson, is currently incarcerated at San Luis Obispo County Jail for the second time this year. His mom said it's his sixth time in jail for alleged offenses related to his mental illness.
Robin said she recognizes the difficulties experienced by community members, particularly those with severe mental illness, but said she does not have the resources to "fix all the problems."
"I've been dedicated to this population and to this work for 40 years on public behavioral health," Robin said. "I am not dedicated to fix and nor may I fix all the problems for everybody in the community, even if I would like to, because I'm simply not resourced to do so."
Grand jury: Emergency rooms strained by psychiatric patients
Beyond addressing the needs of MediCal psychiatric patients, Behavioral Health is primarily responsible for delivering mental health services for people in crisis, including those placed on an involuntary mental health hold — also called a 5150 hold — or 5585 hold, which is just for youth.
A person is placed on a mental health hold if they are deemed a danger to themselves or others or are unable to care for their most basic needs.
"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."
There are numerous bottlenecks in the system that can leave a patient placed on an involuntary psychiatric hold languishing in local emergency rooms for a matter of hours or even days, the report said.
After being placed on a psychiatric hold, a person is transported to one of four local hospitals for a medical evaluation. This medical screening is a step many inpatient psychiatric hospitals require prior to admission, Robin said.
Next, someone from Behavioral Health is dispatched to the emergency room to conduct a mental health evaluation to determine if the patient requires specialty care at a locked inpatient psychiatric hospital.
If so, the patient needs to be transported to that facility and provided a bed.
Responsibility for mental health evaluation and transportation should fall on the shoulders of the medical hospitals under federal law but is inappropriately diverted to Behavioral Health, Robin said.
"There's so many complications and so many things that they only got half correct," Robin said of the grand jury report.
Once the medical screening is completed, eligible patients can go to the 16-bed Psychiatric Health Facility in San Luis Obispo, also known as the PHF or "puff." It's the only psychiatric hospital in the county.
The facility only accepts adult patients on MediCal, those coming from the county jail or people who are otherwise unable to pay for services.
Finding a bed at an inpatient psychiatric facility is also challenging "for held persons who have private insurance, the elderly and juveniles," the grand jury report says. "In fact, some might describe that process as a tortuous gauntlet that no one should have to endure, especially at such a vulnerable and critical time in their lives."
The grand jury report says the wait time at local emergency rooms can last anywhere from a few hours to up to three weeks, noting that anyone on a mental health hold who tests positive for COVID-19 is likely looking at a minimum 10-day emergency room stay.
While patients on a mental health hold sit in the emergency room, the hospital is required to have a staff member, called a "sitter," monitor the patient at all times, the report said.
"That really impacts the ability of the emergency rooms in most cases to handle other patients," Tracy said.
Robin said Behavioral Health has stepped up to help clear the psychiatric patient backlog despite it being outside the scope of the agency's responsibilities.
"We have already dedicated 24/7 staff to assist with placement and transfer even though that is not 100% our role," Robin said. "We will continue to provide that service to all four emergency departments."
Warehousing psychiatric patients at local emergency rooms comes at a significant cost to both local hospitals and the patient, the report says.
By treating local emergency rooms as the starting point for psychiatric services, hospitals could lose the ability to treat up to eight emergency room patients for every person placed on an involuntary psychiatric hold awaiting evaluation and placement, according to the report.
"It really surprised us, the kind of treatment that people were getting," Tracy said. "Having to spend days in the emergency room, it's ... not exactly the easiest thing for the people who are the patients, but it's also a tremendous role for the hospitals that have to staff them."
By staying in the emergency room as they wait for evaluation and transfer to a psychiatric unit, the patient risks a deteriorating mental state, the report says.
"SLO County has failed to create and maintain a safe, orderly, effective and efficient means for ensuring that persons experiencing mental health issues receive the care they need, when they need it," according to the report.
Report seeks SLO County solution for youth in crisis
In its report, the grand jury directs SLO County to establish a psychiatric care continuum for local youths.
"The county has no facilities at all for people under 18," Tracy said. "They all go out of the county — even privately insured kids. They can end up going to places outside of the state even."
Youth in crisis must be transferred out of county because there are no acute psychiatric hospital beds for minors in San Luis Obispo County.
A few weeks before her death in February 2021, Atascadero teenager Reidly Varner was placed on a 5585 hold and spent two days in the emergency room of Sierra Vista Regional Medical Center in San Luis Obispo waiting for a bed at an inpatient psychiatric facility that treated teenagers, according to Tribune archives.
Varner stayed at Sierra Vista before being sent to a facility in Bakersfield because there are no inpatient psychiatric beds for children in San Luis Obispo County.
"That really was a shocker to me," Tracy said. "There was no place to put her."
Robin said Behavioral Health is aware of the local increase in the number of young patients in need of acute psychiatric care.
"We have seen more minors who would benefit from an inpatient stay," Robin said, particularly due to the isolation of the COVID-19 pandemic. "We have some plans to address that but that takes a while."
Behavioral Health is working with a nonprofit partner to build a crisis continuum service center in the North County that serves youth, Robin said. The project is ongoing.
Grand jury: Gaps in behavioral health services create 'revolving door' for patients
Initially, the grand jury investigation focused on interactions between law enforcement and people placed on mental health holds, the report says.
But the focus soon widened to an assessment of the broader mental health system as key problems emerged for patients that are not on holds but use services delivered by Behavioral Health.
"The county has created something of a revolving door that almost ensures that people experiencing mental health issues will cycle through the system again and again in a virtually endless loop," the report says.
Robin said legal constraints about how long a person can be held involuntarily at an inpatient psychiatric facility mean patients may be discharged seemingly prematurely.
One of the key gaps in the local system is the lack of step-down services, such as an adult residential facility, that would allow a person discharged from an involuntary hold at a psychiatric hospital to access a higher level of care than outpatient therapy and psychiatric services, Robin said.
"Behavioral health, mental health is tricky because unless you hit a certain level, the services are voluntary," she said.
Behavioral Health is in talks with local nonprofit groups to develop an adult residential facility but the high cost of real estate locally has made it difficult to acquire a property to house the facility, Robin said.
"It's a hard needle to move," she said.
Behavioral Health has a crisis stabilization unit (CSU) in San Luis Obispo where adults who are not deemed eligible for a mental health hold but are still in crisis can go voluntarily. A patient's stay at the unlocked facility cannot exceed 24 hours, the report says.
Behavioral Health contracted with the Sierra Mental Wellness Group to staff the San Luis Obispo unit, and the grand jury report illuminates tensions between agency staff and contractors to the detriment of patients.
In August 2021, Sierra contractors at the CSU told county staff the facility was full of patients and couldn't accept a transfer but a review of security camera footage showed the facility was empty, according to the report.
In another instance, a Sierra contractor was seen making an "obscene hand gesture" in the direction of a county employee, the report said, although it doesn't specify when that occurred.
That was a point of concern from the grand jury, Tracy said.
Workforce challenges complicate availability of services
The grand jury report also pointed to a staffing shortage at Behavioral Health.
The report said the three agency-run mental health outpatient clinics are staffed with the full-time equivalent of 22.5 mental health professionals, 11.5 therapists and 11 psychiatric technicians who dispense medications, the report says.
The providers manage a caseload of 1,633 people at the time of the grand jury report at a ratio of 150 patients per therapist, according to the report. The recommended caseload for a single psychiatric therapist is 25 to 30 patients.
Psychiatric technicians are stepping up to help despite it being a violation of their licenses which could expose the county to liability, according to the report.
Robin said the grand jury identified a specific example of a licensed psychiatric technician who raised a concern during their annual assessment.
"We did do some changes to that, and so far have not had any further complaints," Robin said.
Behavioral Health also contracts with 70 private practice therapists who help manage patients with mild to moderate mental health conditions, according to the report.
Severely mentally ill patients don't often work with the private practice therapists and have long waits between appointments with the county therapist or technician who manages their medication.
"It is not uncommon for such severely affected clients to wait months before they can see a therapist," the report says.
The staffing shortage is not a problem unique to San Luis Obispo County. Behavioral health departments at counties throughout California experienced a 20% to 30% staffing shortage over the past year, Robin said.
Some of the factors behind the SLO County shortage are competition with other local and state level agencies such as the state-run California Men's Colony prison and Atascadero State Hospital, and the flexibility of tele-health and potential to make more money through private practice, Robin said.
Another recruitment challenge is the cost of living in San Luis Obispo County.
"Candidates are interested in coming here from the (Central) Valley from other places and then they look at the rental market and the housing market and they say 'Gosh, I just can't do it,' " Robin said.
Behavioral Health is trying to develop creative solutions to recruit more clinicians to help bridge the gaps in outpatient services, beyond just paying higher salaries, she said.
In the meantime, the grand jury report said workforce shortage at Behavioral Health has very real impacts for community members who rely on the agency to deliver mental health services.
"During that time they have been released to the street and effectively disappear from the county's system until they turn up again at one of the four hospital emergency rooms or at the county jail," the report said.
Grand jury: Misalignment between Behavioral Health's policies and procedures
The grand jury said there were numerous examples where Behavioral Health policies didn't line up with practices at the agency.
"The grand jury heard testimony time after time from actual service providers about actions they either took or were unable to take that reflected a direct contradiction to established county policy," the report says.
Robin said the claim is difficult to address absent any specific examples.
Robin said the grand jury report pointed to gaps the Behavioral Health department is aware of and is working to rectify, but said she felt the report was written based on testimony from people who disagree with her approach.
"The complaints they received from some very vociferous voices who don't agree with me painted a picture that I believe is inaccurate," she said.
In the report, jurors recommended that the 2022-23 grand jury conduct a deeper investigation into the "human and financial costs of the current county approach to the delivery of mental health services."
Jurors also recommended the county develop one integrated center for all existing county mental health programs, plus the addition of juvenile mental health services and medical triage and screenings; cease sending people on mental health holds to emergency rooms and find the money to appropriately staff outpatient mental health services and hire staff to care for youth on mental health holds.
The grand jury also recommended that Behavioral Health, the San Luis Obispo County Sheriff's Office and San Luis Obispo County Board of Supervisors work together to train and certify corrections officers to protect county staff and patients on mental health holds regardless of the facility.
The board, Behavioral Health and Sheriff's Office are required to respond to the relevant recommendations advanced by the grand jury.
The board and Sheriff's Office has 60 days to respond and Behavioral Health has 90 days to respond after receiving the report, Tracy said.
This story was originally published August 3, 202210:00 AM.
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