New Mandate Could Further Stress San Diego’s Clogged Behavioral Health System

A lack of long-term care options for patients with behavioral disorders that has fueled a congested care system for years became an even bigger problem during the pandemic.

The COVID-19 crisis, which restricted access to health care, further exposed San Diego County’s deficit in step-down psychiatric care and housing, which had already resulted in long waits in hospital beds and delays for others seeking hospital care searched.

County data obtained by Voice of San Diego shows that the number of days adult behavioral patients with Medi-Cal insurance were in hospital beds waiting for post-hospital care increased 48 percent between fiscal 2020 and 2021.

A safety assessment form in a medical exam room at Sharp Mesa Vista Hospital on September 20, 2022. / Photo by Ariana Drehsler

Patients also spent a total of more than 19,000 days waiting in hospital beds across the region after doctors decided they were ready to be discharged to a lower tier of care during the fiscal year that ended this June. That total is 40 percent higher than the wait times reported two years ago.

Those waits have wreaked havoc on the rest of the system, and a forthcoming state mandate to provide and enforce treatment through the state’s new CARE Court initiative by October 2023 will put even more pressure on the region’s limited resources. Failure by the district to provide the care ordered by the civil court to participants in the CARE Court could result in fines of up to $1,000 per day.

Steve Koh, chief of general psychiatry at UC San Diego Health, said he worried more patients would be waiting in emergency rooms without new long-term options.

“Where should I send them to?” he said.

County officials, who in recent years have focused most of their investments on crisis services rather than back-end resources expected to be crucial landing spots for CARE Court participants, are promising action. They plan to soon present an analysis of the region’s needs for longer-term care opportunities and an expansion strategy.

County supervisors also recently established a training fund to address the area’s shortage of behavioral health professionals. County Board of Supervisors Chair Nathan Fletcher argues that the shortage is hampering efforts to expand services.

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Fletcher and Mayor Todd Gloria, both advocates of CARE court reforms, note that Gov. Gavin Newsom has done so provided significant funding to help counties expand their behavioral health systems, including $1.5 billion for bridge housing.

Clearing existing clogs in the behavioral health system — and providing care for CARE Court participants — will likely depend on the county’s ability to supply new beds.

Historically, there have been three phases in the medical care of patients in psychiatric distress: the emergency room, an inpatient hospital bed for patients to stabilize in, and follow-up care for specialized treatment.

A deficiency in the latter category has resulted in a system-wide backup.

Exhibit A: On a single day in late August, 10 of the 36 behavioral health inpatient beds at Scripps Mercy Hospital in Hillcrest were filled with patients waiting to transfer to a different level of care, meaning more than a quarter of Scripps’ beds were not available for crisis patients.

The county has funded so-called crisis stabilization units in recent years so fewer psychiatric patients come to local emergency rooms and then inpatient beds, but patients still have somewhere to go after they leave local hospitals.

Those hospitalized patients waiting for beds at long-term care facilities waited an average of 48 days between July 2021 and April, according to county data obtained by Voice.

Christiana Paul, vice president of Sharp Mesa Vista Hospital, said wait times are challenging for both patients and hospital staff.

“It just really keeps that person with us for those long periods of time where that person has cycles of great improvement and then (they) can even regress due to the length of time in the hospital, which is very demoralizing for the patient and the staff.” said Paul.

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Psychiatric social worker Carrie Dillon speaks with another team member about the discharge of a patient from Sharp Mesa Vista Hospital on September 20, 2022. Dillon and her colleagues are tasked with finding step-down places for patients who need additional care after leaving the hospital. / Photo by Ariana Drehsler

Long wait times also affected the San Diego County Psychiatric Hospital. The county reports that the average wait times for moving patients from the county hospital to a state hospital increased to an average of about three years from July 2020 to June 2021. That’s up from about five months in fiscal 2019.

“Sometimes we have to choose a different level of care, or they’re waiting in the hospital until we can accommodate them,” said Annie Vizcarra, social services director at the Alvarado Parkway Institute.

Aaron Mellon, a trained peer counselor with bipolar disorder who has grappled with homelessness for more than a decade, estimates he’s watched a few dozen friends stabilize in hospitals, only to be forced back onto the streets will.

“For a lot of people, it’s an endless loop,” Mellon said.

Anastasia’s 26-year-old son from Clairemont suffers from bipolar disorder with psychotic features and has been hospitalized several times since 2020.

The clothing is on shelves and will be given to patients as soon as possible, but may vary from patient to patient at Sharp Mesa Vista Hospital on September 20, 2022.

Anastasia said she was repeatedly told there were no openings at boarding houses and nursing homes, which usually offer residents support with medication and better supervision. The homes, long considered essential housing options for people with serious mental illness, are a shrinking resource nationwide.

After a five-day hospitalization for an infection and another five days in a nursing facility this spring, Anastasia and her son’s case managers agreed that he should not return to his independent residential home, but there was no place in a boarding house and foster home.

He moved into her home in Clairemont and forced Anastasia to get permission to work from home.

Carol, a retired teacher living in Tierrasanta, said her 41-year-old daughter, who was diagnosed with schizophrenia, has been kicked out of more than 15 independent residential homes over the past 13 years. Several facility managers have said that she belongs in a retirement and nursing facility.

“She needs a higher level of care,” Carol said.

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In fact, 2-1-1 San Diego reported that the region has lost nearly 400 boarding and nursing beds over the past decade.

Qualified nursing facilities suitable for behavioral patients with medical problems are also scarce.

Psychiatrists say the sicker the patient, the harder it is to find a place for them.

Earlier this year, the state awarded the county $12.4 million for a 12-bed mental health unit at its Edgemoor Skilled Nursing Facility so residents can receive mental health care without having to relocate.

Moving to a mental health rehabilitation clinic also means long waits.

Local hospital systems said wait times have increased significantly during the pandemic but are leveling off at one to three months.

The situation could have been worse. Before the pandemic, the county funded dozens more mental health rehabilitation beds.

Psychiatric social workers Carrie Dillon (left) and Jacqueline Rivera (right) work at Sharp Mesa Vista Hospital on September 20, 2022. You are tasked with finding step-down places for patients who need extra care after they leave the hospital. / Photo by Ariana Drehsler

Since early 2019, the region has also added nearly 2,300 permanent supportive housing places for formerly homeless people deemed to be at high risk — including those with severe mental illness. However, these additions have not dramatically reduced hospital wait times, and many patients with behavioral disorders require more support than these facilities provide.

“The fact is, we just need more post-acute care,” said Dimitrios Alexiou, CEO of the Hospital Association of San Diego and Imperial Counties.

Nadia Privara Brahms of the county’s Behavioral Health Services Division recently told an advisory board the county plans to increase step-down care and will communicate its needs at a Sept. 27 meeting.

“Rather than being stuck in more acute care or not being cared for at all because the levels of care or types of beds they need are not available, the aim is to continue to build capacity, much of which is in the lower, less restrictive areas of care to ensure customers are connected and they can then be cared for long-term,” said Privara Brahms.

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