Part 3: County, hospitals wrestle over a fix for mental health care

Oct. 28--A scarcity of psychiatric beds. Mental patients languishing in overstretched emergency rooms. Assaults on ER doctors and nurses. Longer waits for everyone.

You would be hard-pressed to find a hospital executive, ER worker, police officer, ambulance driver, mental health professional or patient in Orange County who doesn't believe the local mental health network is in urgent need of repair.

After a long period of deterioration, an overhaul may be on the way. But financing could be an obstacle.

Hospitals, emergency room doctors, county officials and law enforcement officers started meeting a year ago to try to hammer out a plan for two dedicated psychiatric emergency centers in Orange County. The centers would be the first destination for ambulances and police officers transporting people who have been put on psychiatric holds, as well as for others in mental distress.

These dedicated psychiatric emergency services -- known by those involved as PES -- would triage patients to determine which ones needed to be admitted to an inpatient psychiatric facility. It could hold them for up to 23 hours in order to stabilize them and avoid the need for hospitalization.

The first of these centers would be created by expanding the current county-run crisis stabilization and triage unit in Santa Ana, known as Evaluation and Treatment Services, or ETS. The expansion would be funded, at least in part, with revenue from the historic 1998 settlement between tobacco companies and the government.

The cost and financing of a second center, envisioned for south Orange County at a later date, is still uncertain -- though one calculation shows that staffing alone would cost $5.2 million a year.

Mental health workers, ER doctors and hospital executives say ETS in its current configuration is way too small, and its mandate too restricted, to meet Orange County's demand for psychiatric services. The planned expansion would more than double the number of beds and upgrade the services, as part of its conversion to the county's first genuine psychiatric emergency service.

The ETS overhaul was to be completed by June 30, 2015, the end of the current fiscal year. But hospital officials have begun to worry that the county may be getting cold feet.

Julie Puentes, regional O.C. vice president of the Hospital Association of Southern California, said she recently received a letter from Mary Hale, the head of Orange County's behavioral health unit, saying the timeline for the improvements "is not currently known and is subject to the county's administration oversight requirements."

After receiving the letter, Puentes is a bit more wary about the whole project than she was earlier this month.

"This is a pretty exciting endeavor that we've undertaken and I'm cautiously optimistic that we can make some changes here in the county and help those patients, and also preserve emergency room space," she says. "But I would add that this assumes we can count on the commitments the county has made for the improvements and their timeline."

Asked about her letter to Puentes, Hale said that expanding ETS "is a priority for the health care agency," which is "fully committed to doing as much as possible during the fiscal year."

The county's director of adult mental health services, Annette Mugrditchian, suggested in an earlier interview that money may be an issue.

"The budget for expanding ETS is being worked on. We are trying to identify where the money comes from," she said.

Although ETS has only 10 beds -- a number that hasn't changed in decades -- Mugrditchian notes that it also serves many patients outside its walls, who are being held in emergency rooms around the county. It has a $3 million-a-year grant from the state to put social workers in hospital ERs for the purpose of triaging psych patients.

In its last fiscal year, the agency saw about 5,700 patients, at its own facility and in ERs, and it put a little more than half of those people into inpatient psychiatric beds around the county.

But ETS is limited by its mission: It only accepts patients who are uninsured or on MediCal, the government insurance program for low-income people. That means privately insured or Medicare patients suffering an acute psychiatric crisis typically have nowhere to go initially other than the emergency room.

Even for the population ETS does serve, its 10 beds are woefully insufficient.

"It gets filled up right away, and the county is using the emergency departments throughout the county as their holding area," says Peter Anderson, an emergency room physician who is affiliated with three emergency rooms in Orange County.

The number of psych beds elsewhere in the county is also insufficient. Across O.C., there are 16.6 psych beds per 100,000 residents, less than one-third the number mental health experts say is the minimum required.

In Los Angeles County, that ratio is significantly higher -- 23.8 beds per 100,000 -- though still less than half the recommended minimum. L.A., unlike Orange County, has three county-run hospitals, and each of the three houses a dedicated psychiatric emergency service like the one being considered here.

In O.C., the county's behavioral health department has designated several hospitals as destinations for patients who have been put on involuntary psychiatric holds. The four biggest are College Hospital in Costa Mesa, Western Medical Center-Anaheim, UCI Medical Center and St. Joseph Hospital in Orange.

Given the particular needs of psychiatric patients, and the fact they frequently stay for a long time in the emergency room, some ERs have begun putting the most unstable ones in separate units where they will be apart from non-psychiatric patients and get at least some of the special attention they need while they wait for a psych bed, or to be discharged.

St. Joseph Hospital has a lock-down unit adjacent to the ER, which is staffed by nurses and technicians with psychiatric training, equipped with 12 beds and can keep patients who are on official psych holds for up to 72 hours.

But this emergency clinical decision unit, as the hospital calls it, "is not big enough, nor do we want it to be the county's solution," says St. Joseph CEO Steve Moreau.

Moreau believes if there is a second dedicated psychiatric emergency service, it should not be attached to any hospital, but run by the county with financial support from all the hospitals.

"It has to do with who wants to be identified as the place for all psychiatric patients to go," he says. "Historically and even today, the reimbursement system and complexity of those patients can be a real drain on those hospitals."

Some argue that it would be better if both psychiatric centers were attached to a hospital, or at least operating on a hospital's license. All psychiatric patients need to be screened for other medical conditions, they say, and paramedic regulations dictate that ambulances can only take patients to licensed emergency rooms.

"I can understand the reluctance of hospitals not wanting it to be in their hospital, but there are advantages of having it attached to a hospital license, because then paramedics, by state law, can transport patients to that facility," Anderson says. "However, we can make this work without having one hospital directly involved. It can be an independent facility."

Eight counties around California already have designated psychiatric emergency centers. Those involved in efforts to launch such a service to Orange County have their eyes on Alameda County, whose psychiatric center is widely considered the most successful in the state.

By directing psychiatric patients to that facility, the county was able to reduce ER waiting times of psych patients by 80 percent, according to a study authored by Scott Zeller, the head of Alameda's Department of Psychiatric Emergency Services. And because the environment of the center is tailored for people in mental distress, with appropriately trained staff, it managed to stabilize 75 percent of its patients and avoid the need to hospitalize them.

An emergency psychiatric service like that "could reduce the need for psych beds by giving good, immediate care to patients and stabilizing them," says Anderson. "It would be better care."

Contact the writer: 714-796-2440 or bwolfson@ocregister.com

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