SLO County grand jury experiences on psychological well being system
A San Luis Obispo County civil grand jury report discovered important failings within the methods county companies present psychological well being care for group members — significantly in the case of remedy of individuals on psychiatric holds and the provision of companies for youth.
The grand jury report additionally highlighted a workforce scarcity that’s inflicting delays in remedy.
“SLO County fails to supply the sort of unified, built-in and ‘single’ voice management” wanted to (ship) psychological well being companies in a fashion that meets the wants of our group whereas concurrently respecting and appropriately defending the professionals who attempt to supply such companies,” the 2021-22 grand jury wrote within the report, launched on July 26.
Anne Robin, director of the San Luis Obispo County Behavioral Well being Division, acknowledged there proceed to be gaps within the native psychological well being system — significantly in regard to staffing on the company and an absence of inpatient psychiatric companies for youngsters and the aged.
The foreman of the 2021-22 grand jury, George Tracy, mentioned the investigators found important discrepancies between company insurance policies and practices.
“What we discovered, because the report states, is there are issues that go on that doesn’t actually match what the county says that they’re doing,” Tracy mentioned.
Nevertheless, the jurors didn’t acknowledge limitations and obligations the company faces in the case of delivering psychological well being companies, Robin mentioned.
“I perceive why the grand jury might hear very impassioned voices and listen to that versus trying on the very dry regulation and regulatory points,” Robin advised The Tribune.
Robin mentioned the company is working to establish and implement options to assist bridge the gaps that depart many residents with extreme psychological sickness susceptible.
Exterior components akin to reasonably priced housing, caps on the size of inpatient hospital stays and different components which are past that the company’s management can contribute to mentally in poor health group members biking by the justice and social companies methods, she mentioned.
“Our accountability, because the psychological well being plan for MediCal, is to pay for medically obligatory inpatient companies for MediCal beneficiaries of SLO County,” Robin mentioned. “We aren’t mandated to supply all of them.”
What did grand jury have a look at?
The 2021-22 grand jury, which consisted of 15 to 19 individuals at a time, carried out its investigation from the start of 2021 by June 2022.
Jurors interviewed 16 individuals concerned with psychological well being companies within the county, akin to docs, nurses, hospital executives, county executives, unit supervisors and managers, safety officers and psychiatric care specialists.
Jurors additionally reviewed paperwork, movies and photographs of incidents, previous grand jury experiences, information articles and written correspondence, amongst different objects.
“It’s an excellent report and I feel individuals ought to spend a while studying about what’s occurring within the county for individuals who have actual critical psychological well being points,” Tracy mentioned.
The mom of a SLO County resident who’s dwelling with extreme psychological sickness questioned Behavioral Well being’s will to enhance availability and entry to important psychological well being companies.
“We have to inform the group that what you hear from Anne Robin and what we’re getting don’t match,” Daybreak Marie Anderson, of Los Osos, mentioned.
Anderson’s son, Chris Anderson, is at the moment incarcerated at San Luis Obispo County Jail for the second time this yr. His mother mentioned it’s his sixth time in jail for alleged offenses associated to his psychological sickness.
Robin mentioned she acknowledges the difficulties skilled by group members, significantly these with extreme psychological sickness, however mentioned she doesn’t have the sources to “repair all the issues.”
“I’ve been devoted to this inhabitants and to this work for 40 years on public behavioral well being,” Robin mentioned. “I’m not devoted to repair and nor might I repair all the issues for everyone in the neighborhood, even when I want to, as a result of I’m merely not resourced to take action.”
Grand jury: Emergency rooms strained by psychiatric sufferers
Past addressing the wants of MediCal psychiatric sufferers, Behavioral Well being is primarily accountable for delivering psychological well being companies for individuals in disaster, together with these positioned on an involuntary psychological well being maintain — additionally known as a 5150 maintain — or 5585 maintain, which is only for youth.
An individual is positioned on a psychological well being maintain if they’re deemed a hazard to themselves or others or are unable to care for his or her most elementary wants.
“On paper there seems to be a wealth of sources being utilized to the challenges related to offering companies to individuals on holds inside our county,” the grand jury report says. “In observe, nonetheless, these companies look like out of attain for a lot of of our most at-risk residents.”
There are quite a few bottlenecks within the system that may depart a affected person positioned on an involuntary psychiatric maintain languishing in native emergency rooms for a matter of hours and even days, the report mentioned.
After being positioned on a psychiatric maintain, an individual is transported to considered one of 4 native hospitals for a medical analysis. This medical screening is a step many inpatient psychiatric hospitals require previous to admission, Robin mentioned.
Subsequent, somebody from Behavioral Well being is dispatched to the emergency room to conduct a psychological well being analysis to find out if the affected person requires specialty care at a locked inpatient psychiatric hospital.
If that’s the case, the affected person must be transported to that facility and offered a mattress.
Accountability for psychological well being analysis and transportation ought to fall on the shoulders of the medical hospitals underneath federal regulation however is inappropriately diverted to Behavioral Well being, Robin mentioned.
“There’s so many issues and so many issues that they solely obtained half right,” Robin mentioned of the grand jury report.
As soon as the medical screening is accomplished, eligible sufferers can go to the 16-bed Psychiatric Well being Facility in San Luis Obispo, also called the PHF or “puff.” It’s the one psychiatric hospital within the county.
The ability solely accepts grownup sufferers on MediCal, these coming from the county jail or people who find themselves in any other case unable to pay for companies.
Discovering a mattress at an inpatient psychiatric facility can be difficult “for held individuals who’ve non-public insurance coverage, the aged and juveniles,” the grand jury report says. “In actual fact, some may describe that course of as a tortuous gauntlet that nobody ought to should endure, particularly at such a susceptible and significant time of their lives.”
The grand jury report says the wait time at native emergency rooms can final wherever from a couple of hours to as much as three weeks, noting that anybody on a psychological well being maintain who exams optimistic for COVID-19 is probably going taking a look at a minimal 10-day emergency room keep.
Whereas sufferers on a psychological well being maintain sit within the emergency room, the hospital is required to have a employees member, known as a “sitter,” monitor the affected person always, the report mentioned.
“That actually impacts the power of the emergency rooms most often to deal with different sufferers,” Tracy mentioned.
Robin mentioned Behavioral Well being has stepped as much as assist clear the psychiatric affected person backlog regardless of it being exterior the scope of the company’s obligations.
“We’ve got already devoted 24/7 employees to help with placement and switch although that isn’t 100% our position,” Robin mentioned. “We’ll proceed to supply that service to all 4 emergency departments.”
Warehousing psychiatric sufferers at native emergency rooms comes at a major price to each native hospitals and the affected person, the report says.
By treating native emergency rooms as the start line for psychiatric companies, hospitals may lose the power to deal with as much as eight emergency room sufferers for each individual positioned on an involuntary psychiatric maintain awaiting analysis and placement, based on the report.
“It actually shocked us, the sort of remedy that individuals have been getting,” Tracy mentioned. “Having to spend days within the emergency room, it’s … not precisely the simplest factor for the people who find themselves the sufferers, but it surely’s additionally an amazing position for the hospitals that should employees them.”
By staying within the emergency room as they look ahead to analysis and switch to a psychiatric unit, the affected person dangers a deteriorating psychological state, the report says.
“SLO County has didn’t create and keep a secure, orderly, efficient and environment friendly means for making certain that individuals experiencing psychological well being points obtain the care they want, after they want it,” based on the report.
Report seeks SLO County answer for youth in disaster
In its report, the grand jury directs SLO County to determine a psychiatric care continuum for native youths.
“The county has no amenities in any respect for individuals underneath 18,” Tracy mentioned. “All of them exit of the county — even privately insured children. They’ll find yourself going to locations exterior of the state even.”
Youth in disaster have to be transferred out of county as a result of there are not any acute psychiatric hospital beds for minors in San Luis Obispo County.
A couple of weeks earlier than her loss of life in February 2021, Atascadero teenager Reidly Varner was positioned on a 5585 maintain and spent two days within the emergency room of Sierra Vista Regional Medical Middle in San Luis Obispo ready for a mattress at an inpatient psychiatric facility that handled youngsters, based on Tribune archives.
Varner stayed at Sierra Vista earlier than being despatched to a facility in Bakersfield as a result of there are not any inpatient psychiatric beds for youngsters in San Luis Obispo County.
“That actually was a shocker to me,” Tracy mentioned. “Tright here was no place to place her.”
Robin mentioned Behavioral Well being is conscious of the native improve within the variety of younger sufferers in want of acute psychiatric care.
“We’ve got seen extra minors who would profit from an inpatient keep,” Robin mentioned, significantly because of the isolation of the COVID-19 pandemic. “We’ve got some plans to deal with that however that takes some time.”
Behavioral Well being is working with a nonprofit accomplice to construct a disaster continuum service heart within the North County that serves youth, Robin mentioned. The undertaking is ongoing.
Grand jury: Gaps in behavioral well being companies create ‘revolving door’ for sufferers
Initially, the grand jury investigation targeted on interactions between regulation enforcement and other people positioned on psychological well being holds, the report says.
However the focus quickly widened to an evaluation of the broader psychological well being system as key issues emerged for sufferers that aren’t on holds however use companies delivered by Behavioral Well being.
“The county has created one thing of a revolving door that just about ensures that individuals experiencing psychological well being points will cycle by the system time and again in a nearly countless loop,” the report says.
Robin mentioned authorized constraints about how lengthy an individual may be held involuntarily at an inpatient psychiatric facility imply sufferers could also be discharged seemingly prematurely.
One of many key gaps within the native system is the dearth of step-down companies, akin to an grownup residential facility, that will enable an individual discharged from an involuntary maintain at a psychiatric hospital to entry a better stage of care than outpatient remedy and psychiatric companies, Robin mentioned.
“Behavioral well being, psychological well being is hard as a result of until you hit a sure stage, the companies are voluntary,” she mentioned.
Behavioral Well being is in talks with native nonprofit teams to develop an grownup residential facility however the excessive price of actual property domestically
has made it troublesome to amass a property to accommodate the power, Robin mentioned.
“It’s a tough needle to maneuver,” she mentioned.
Behavioral Well being has a disaster stabilization unit (CSU) in San Luis Obispo the place adults who will not be deemed eligible for a psychological well being maintain however are nonetheless in disaster can go voluntarily. A affected person’s keep on the unlocked facility can’t exceed 24 hours, the report says.
Behavioral Well being contracted with the Sierra Psychological Wellness Group to employees the San Luis Obispo unit, and the grand jury report illuminates tensions between company employees and contractors to the detriment of sufferers.
In August 2021, Sierra contractors on the CSU advised county employees the power was stuffed with sufferers and couldn’t settle for a switch however a evaluate of safety digital camera footage confirmed the power was empty, based on the report.
In one other occasion, a Sierra contractor was seen making an “obscene hand gesture” within the course of a county worker, the report mentioned, though it doesn’t specify when that occurred.
That was a degree of concern from the grand jury, Tracy mentioned.
Workforce challenges complicate availability of companies
The grand jury report additionally pointed to a staffing scarcity at Behavioral Well being.
The report mentioned the three agency-run psychological well being outpatient clinics are staffed with the full-time equal of twenty-two.5
psychological well being professionals, 11.5 therapists and 11 psychiatric technicians who dispense drugs, the report says.
The suppliers handle a caseload of 1,633 individuals on the time of the grand jury report at a ratio of 150 sufferers per therapist, based on the report. The beneficial caseload for a single psychiatric therapist is 25 to 30 sufferers.
Psychiatric technicians are stepping as much as assist regardless of it being a violation of their licenses which may expose the county to legal responsibility, based on the report.
Robin mentioned the grand jury recognized a selected instance of a licensed psychiatric technician who raised a priority throughout their annual evaluation.
“We did do some adjustments to that, and up to now haven’t had any additional complaints,” Robin mentioned.
Behavioral Well being additionally contracts with 70 non-public observe therapists who assist handle sufferers with gentle to average psychological well being situations, based on the report.
Severely mentally in poor health sufferers don’t usually work with the non-public observe therapists and have lengthy waits between appointments with the county therapist or technician who manages their remedy.
“It isn’t unusual for such severely affected purchasers to attend months earlier than they will see a therapist,” the report says.
The staffing scarcity is just not an issue distinctive to San Luis Obispo County. Behavioral well being departments at counties all through California skilled a 20% to 30% staffing scarcity over the previous yr, Robin mentioned.
A number of the components behind the SLO County scarcity are competitors with different native and state stage companies such because the state-run California Males’s Colony jail and Atascadero State Hospital, and the pliability of tele-health and potential to earn more money by non-public observe, Robin mentioned.
One other recruitment problem is the price of dwelling in San Luis Obispo County.
“Candidates are excited about coming right here from the (Central) Valley from different locations after which they have a look at the rental market and the housing market they usually say ‘Gosh, I simply can’t do it,’ ” Robin mentioned.
Behavioral Well being is attempting to develop artistic options to recruit extra clinicians to assist bridge the gaps in outpatient companies, past simply paying larger salaries, she mentioned.
Within the meantime, the grand jury report mentioned workforce scarcity at Behavioral Well being has very actual impacts for group members who depend on the company to ship psychological well being companies.
“Throughout that point they’ve been launched to the road and successfully disappear from the county’s system till they flip up once more at one of many 4 hospital emergency rooms or on the county jail,” the report mentioned.
Grand jury: Misalignment between Behavioral Well being’s insurance policies and procedures
The grand jury mentioned there have been quite a few examples the place Behavioral Well being insurance policies didn’t line up with practices on the company.
“The grand jury heard testimony time after time from precise service suppliers about actions they both took or have been unable to take that mirrored a direct contradiction to established county coverage,” the report says.
Robin mentioned the declare is troublesome to deal with absent any particular examples.
Robin mentioned the grand jury report pointed to gaps the Behavioral Well being division is conscious of and is working to rectify, however mentioned she felt the report was written based mostly on testimony from individuals who disagree along with her method.
“The complaints they acquired from some very vociferous voices who don’t agree with me painted an image that I imagine is inaccurate,” she mentioned.
Within the report, jurors beneficial that the 2022-23 grand jury conduct a deeper investigation into the “human and monetary prices of the present county method to the supply of psychological well being companies.”
Jurors additionally beneficial the county develop one built-in heart for all current county psychological well being packages, plus the addition of juvenile psychological well being companies and medical triage and screenings; stop sending individuals on psychological well being holds to emergency rooms and discover the cash to appropriately employees outpatient psychological well being companies and rent employees to take care of youth on psychological well being holds.
The grand jury additionally beneficial that Behavioral Well being, the San Luis Obispo County Sheriff’s Workplace and San Luis Obispo County Board of Supervisors work collectively to coach and certify corrections officers to guard county employees and sufferers on psychological well being holds whatever the facility.
The board, Behavioral Well being and Sheriff’s Workplace are required to reply to the related suggestions superior by the grand jury.
The board and Sheriff’s Workplace has 60 days to reply and Behavioral Well being has 90 days to reply after receiving the report, Tracy mentioned.