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San Diego County seeks shift away from locked psychiatric units. 'The change that we need in behavioral health is dramatic'

San Diego Union-Tribune - 9/24/2022

Two out of every five psychiatric hospital admissions can be prevented.

That is the conclusion of a new report before the county Board of Supervisors Tuesday that provides the greatest detail yet on how the region's overwhelmed behavioral health system can be reshaped.

Dubbed the county's "Optimal Care Pathways Model," the plan shies away from significantly increasing the region's overall number of hospital beds dedicated to mental health care, instead predicting that investments in less-restrictive venues such as nursing homes and "respite centers" will be more effective at solving the current mental health crisis over the long run.

Overall, the report suggests that having more low-key resources available to people early on in their course of illness will significantly reduce the need for the most-restrictive kinds of care, meaning a large increase in hospital-level resources would be a bad investment.

"A lot of the system pressure that we feel right now doesn't reflect a dramatic increase in the prevalence of serious mental illness," said Luke Bergmann, the plan's architect and director of behavioral health for San Diego County. "It's reflecting the fact that we don't have a continuum of care that is designed around what we know about behavioral health, which is that it is a chronic, relapsing condition that is best managed through continuous care."

After reading the document, Linda Mimms, a Poway resident and vice chair of the Schizophrenia & Psychosis Action Network, an advocacy and activism group operating in Southern California, said she appreciated the big picture take but has concerns about the details.

Today, she said, those suffering from severe mental illness such as schizophrenia are too often cycling in and out of hospital units due to a lack of beds. A long-term plan to fix the mental health system that does not commit to significantly increasing the inpatient units, she said, feels like it doesn't fully address the needs that are currently staring the community in the face.

"I'm just really concerned about our sickest people who don't even realize they're sick, the ones who have so far been left out of this continuum of care who are on our streets, in our jails," Mimms said. "We really need to devote major resources to that population."

Bergmann said he agrees that more beds are needed in the here and now, and pointed to ongoing projects, such as adding more capacity at Tri-City Medical Center in Oceanside and to Alvarado Hospital in La Mesa, as proof that his department recognizes the immediate need.

But he added that research shows that a shift in long-term thinking is also needed.

"Right now we really do have a system that's predominately defined by repeated episodes of crisis care, but we think that the preponderance of those can be reshaped, can be recalibrated," Bergmann said. "There will absolutely still be a need for acute inpatient psychiatric care, and there will still be a need for judiciously applied conservatorship."

A new path

The county built its model by working with Public Consulting Group, a national firm specializing in public sector process improvement, to analyze data on current patterns of care.

Bergmann said he believes that the effort was comprehensive enough to accurately show what needs changing and left him with a core belief that a more preventive strategy can work.

"This has been a very rigorous analytic effort, and what we're saying is we think we can prevent as much as 40 percent of the utilization of inpatient care," Bergmann said. "If those seem like audacious remarks, they should, because the change that we need in behavioral health is dramatic."

The biggest new investments would come in the parts of the system designed to function before and after hospitalization.

On the front end, the model calls for creation of "crisis respite" centers to provide up to a week of lower-intensity treatment for those who may first be brought to one of the region's growing number of crisis-stabilization centers, locations where adults can stay in recliners and under psychiatric supervision for up to 24 hours.

Respite centers would offer a longer path, perhaps operating in residential homes or other low-key "warm and welcoming settings" staffed by a mix of peer workers and clinicians trained to provide higher-level treatment.

The model projects that nearly 126,000 "bed days" of such respite care would be needed to meet local demand. Bed days account for the amount of time patients receive treatment. A seven-day hospital stay, for example, would equal seven bed days.

Peer support workers

Adding a new category of residential resource is a particularly ambitious goal given the current mental health worker shortage. A recent report from the San Diego Workforce Partnership estimated that the community needs 8,000 more qualified people to meet demands today and that needs to roughly double in size to handle future demands.

Respite plans would capitalize on a coming state-level change that formalizes a commonly-relied-upon category of mental health workers called peer support specialists. Generally, these women and men have themselves recovered from an acute episode of mental illness, making them particularly effective at working with those in the midst of coping with similar situations.

Whether it's leading peer support groups, encouraging the people they work with to take medications they have been prescribed or making sure they get to counseling appointments, peer support is increasingly being embraced as a foundational resource at the base of the mental health care system.

In California, this work has always had an informal connotation, but that began to change in 2020 with the passage of a bill that allows peer support workers to take a state proficiency test and become certified. While the full testing system is not yet up and running, it is expected to offer a path to better pay and Medi-Cal reimbursement soon.

Bergmann said he has seen certified peer support workers significantly extend the reach of the mental health workforce in Detroit and New York, locations where he worked before coming home to San Diego. Such outreach is particularly effective, he said, in treating those with substance abuse disorders that are causing symptoms of mental illness.

"Peer support has been demonstrated in rigorous research to be particularly effective at keeping people engaged in care and preventing future episodes of crisis," Bergmann said.

At the moment, he said, too many people who could be better served in a respite center are receiving little or no treatment until they end up at a place where someone calls 911, resulting in a hospital stay that could have been avoided.

Long-term treatment

For those whose mental illness requires more-intensive help, the county's plan proposes investing more heavily in skilled nursing centers. At the moment, many patients end up spending months or even years in hospital units because there are not nearly enough "step down" beds to handle the demand for the kinds of long-term treatment some need.

A particularly massive increase is recommended for skilled nursing facilities that specialize in neurobehavioral treatment. The region is said to currently provide about 4,000 bed days of such care annually but the modeling predicts that this resource should be increased 13-fold to nearly 55,000 bed days of capacity per year.

Another category concerns places where people recovering from severe mental illness can live after they receive treatment. In recent years, the region has seen sharp decreases in "board and care" and other adult residential facilities and in residential care facilities for the elderly. The right number in this category, county research suggests, is about 233,000 bed days, nearly three times the 88,000 now available.

Mimms said she sees a fierce need both for longer-term treatment and for a place for those who spend months or years inside a mental health facility to land when discharged back into the community. She remains skeptical, though, about whether skilled nursing centers will be able to serve patients who often struggle to recognize that they need treatment.

"For somebody with severe mental illness who is not able to be stabilized quickly, I don't see putting them in an unlocked facility would do any good because they would just walk away," Mimms said.

Bergmann said that neurodevelopmental skilled nursing centers can operate locked units, though they are not required to do so.

The plan that the supervisors will discuss Tuesday is a roadmap that does not quite get down to specific initiatives in specific locations with specific numbers of beds.

Cost is also a big open question, though the roadmap does suggest that reducing the number of mental health-related admissions would save money, freeing up resources to plow into the community-level resources suggested.

The county's latest behavioral health update also indicates that the region's next crisis stabilization hub will be be built in El Cajon, but does not list a specific location.

This story originally appeared in San Diego Union-Tribune.

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