San Luis Obispo County's civil grand jury says that local mental health services have not kept pace with a growing population, leading to serious lapses in access to treatment.
Bottom line: the SLO County Behavioral Health Department needs more money to do its job, the jury says.
Though Behavioral Health staff were commended for their dedication and the quality of treatment was not questioned, two grand jury reports released late last week focus on where demand for local services has resulted in staffing, bed availability or other shortages, as well as the need for a new psychiatric inpatient facility for people in mental health crises.
The County Health Agency, which administers the Behavioral Health Department, and the Board of Supervisors are required to respond to the grand jury's specific recommendations by filing responses to San Luis Obispo Superior Court Presiding Judge Ginger Garrett by July 9 and 10, respectively.
Though it's required to respond, the county's not bound to comply with any recommendations.
Behavioral Health Director Anne Robin on Tuesday said the agency did not have any comment on the reports at this time but will file its responses by the deadline.
Grand Jury Foreperson Bill McQuilkin said Tuesday that members of the jury are also unable to comment on their investigations or deliberative process and their reports must speak for themselves.
Roughly 5,000 people in San Luis Obispo County suffer from severe mental illness, though the report does not state how many of those are Medi-Cal beneficiaries dependent on county services for treatment, as opposed to patients with private insurance.
"As the national mental health crisis continues, the public is still affected by the closure of the state mental hospitals, which occurred decades ago," the report states. "The population once served in these institutions is now often found in judicial custody, on the streets, or being cared for by family members. (They) desperately need the services only the county can provide."
According to the grand jury, the reports were generated in response to citizen complaints and "recent events concerning the treatment of behavioral health patients within our county."
Behavioral Health improvements
The county is mandated to provide mental health services to Medi-Cal recipients with severe mental illness, as well as provide drug and alcohol services. The 2014-15 grand jury previously noted that wait times for outpatient services were too long and that inpatient services at the 16-bed psychiatric health facility — known as the PHF — were often unavailable due to high demand.
The report notes that many of Behavioral Health's clients are referred to them while in the midst of crisis. The grand jury noted that well under half of local police officers have completed a 40-hour crisis intervention course (many complete shorter courses), and that crisis at the street level is best handled by the Behavioral Health Department's Mental Health Evaluation Teams, which include mental health professionals rather than uniformed police officers in order to deescalate emergencies.
However, there are currently two teams assigned to the whole county, leading to delays and forcing law enforcement or emergency rooms to deal with people in crisis.
The jury commended the county for opening its 23-hour Crisis Stabilization Unit last month, where contracted health professionals provide a temporary space for patients to receive treatment and evaluation if their situation is not dire enough to require admittance to the PHF.
After a crisis is abated, patients are usually referred to voluntary outpatient services, though currently half of SLO County's severely mentally ill population don't use those services.
There are three county outpatient facilities — in SLO, Arroyo Grande and Atascadero — but new clients there wait for up to 14 days for an assessment and up to 40 days for initial treatment, the grand jury found. New state mandates require that those wait times be no more than 10 days.
Staffing is also a problem. The grand jury says that many county psychiatrist positions are filled by a "revolving door" of contractors due to a nationwide shortage of psychiatrists that affects local and state facilities.
Beyond additional funding for Behavioral Health and county housing programs, the report recommends that the county cross-train Behavioral Health clinicians in both drug and alcohol as well as mental health treatment, use incentives such as county-backed bonds or tax breaks to support the building of private psychiatric and substance abuse facilities, and more aggressively recruit psychiatrists, nurses and nurse practitioners.
It also recommends adding two additional Mental Health Evaluation Teams, one each for North and South County.
"(These) issues are complex, partially because this community has been underserved for so long," the report states. "(Now) is the time to increase our effort to work toward a long-term solution."
PHF in 'crisis'
The grand jury also called the county's 16-bed psychiatric facility (PHF) in the county's old hospital complex on Johnson Avenue "antiquated and unsafe" and noted that it hasn't been modernized in over 25 years even though the county's population has grown by more than 25 percent in that time.
The facility temporarily houses and provides psychiatric treatment to county residents facing mental health emergencies as well as County Jail inmates in need of competency restoration for misdemeanor court cases.
"The grand jury members who visited the facility were utterly dismayed that a county facility in this poor condition could be used to treat patients," the report reads.
Most significantly, the grand jury recommends the county come up with a plan to replace the PHF with a modern facility using reserve county and Mental Health Services Act funding or through state grants, though the jury admits that that will take considerable time. Until the county can do that, jurors recommend expanding the existing PHF and building a similar facility at County Jail.
The Sheriff’s Office is expecting to open a newly constructed medical building at the jail, and is planning to repurpose the old medical building into an on-site mental health treatment and housing area. Plans for that facility have not been finalized.
The grand jury noted that the PHF is old, not well-maintained, crowded, and does not contain dedicated spaces for therapy, physical exercise, or other treatments. Furthermore, county policy dictates that juveniles — segregated from adult patients — are not treated at the PHF if the facility is housing a jail inmate. This means that juveniles are often forced into treatment outside the county, possibly conflicting with treatment involving family therapy, the report reads.
Up to 10 staff members man the facility, which has its bed limit imposed by Medicaid for psychiatric facilities not attached to a hospital. There is no room in the facility for patients' physical exercise, the report states, and an administrative office, a medical examination room and a common area each double as therapy areas due to extreme lack of space.
There were also safety concerns: During the grand jury's inspection, supplies were stacked high enough to impede fire sprinklers and some was stored near emergency exists. The surveillance system also is low resolution and appears quite old, the report notes.
In a possible safety issue for surrounding neighborhoods, an emergency evacuation of the facility would give patients — including jail inmates — "a nearly unfettered path for escape" due to low staff-to-patient ratios.
The report recommends building a psychiatric facility at the jail to limit inmates' impacts to PHF operations. It also recommends replacing the "office-type" PHF lighting with LED lights, repainting the interior, and replacing the ceiling tiles to provide a more therapeutic environment.
The county Board of Supervisors is currently deliberating a proposed fiscal year 2018-19 budget and has indicated it wants to increase Behavioral Health funding.
Deficiencies in mental health services and resources has been highlighted recently by the death of a schizophrenic County Jail inmate who had languished in the local mental health and criminal justice system for years.
In the last year, the county's treatment of mentally ill patients and inmates has been the subject of several administrative claims and lawsuits, and resulted in a $5 million settlement to the family of deceased inmate Andrew Holland.
Several of the 12 inmates to die in custody at the jail since 2012 had mental health needs that weren't met or were exacerbated by their treatment in jail custody.