Challenges of providing mental health care in SLO County
San Luis Obispo County mental health program supervisor Brian Atwell slid a key into a locked door to the county’s Psychiatric Health Facility, allowing a few people into a small but clean area.
Local photography adorned the walls, with a recurring ocean theme designed to inspire calm.
“Even though it’s not optimal with what we have, we want to provide a home,” Atwell said on a recent afternoon.
The 16-bed inpatient Psychiatric Health Facility, or PHF, provides care for people suffering from a host of mental illnesses. The small hospital, which is licensed by the state, is run by the county’s Behavioral Health Services.
In addition to the inpatient care at the psychiatric hospital, the county provides outpatient mental health services at five clinics around the county and through partnerships with local nonprofit groups. A county mobile crisis team responds to emergency calls, making assessments and referring people to the appropriate services.
The PHF, or “puff” as it’s called, is the only psychiatric hospital for the general public in San Luis Obispo County and serves patients in their worst stages of a mental health crisis. On a recent tour, the PHF had five adults and one minor. “But that can change in an instant with people coming in from the jail or elsewhere,” Atwell said. Admittance is limited primarily to patients on Medi-Cal, California’s health program for low income residents.
Patients with insurance may be evaluated and, if they require hospitalization, transferred to a psychiatric facility out of the county.
“For people with private insurance — there’s no place for them currently,” said Anne Robin, the county’s Behavioral Health Services administrator.
The county Psychiatric Health Facility opened in 2003 after the county’s General Hospital closed, along with its psychiatric unit.
The PHF is housed inside part of the old General Hospital building on Johnson Avenue in San Luis Obispo.
The 1,800-square-foot hospital offers bedrooms, a group treatment room, common area, an inter view room for patient-doctor interactions and a fenced patio. It doesn’t have a cafeteria, so the county contracts with French Hospital Medical Center to bring meals over from across the street.
A locked entry door opens into a long hallway that leads to an activity room where, on a recent afternoon, a few patients sat at a table and worked on brush strokes and watercolor paintings.
“Art segues into other conversations, like how they’re feeling today,” rehabilitation therapist Tom Velasquez said.
Off that room is a common area with chairs, newspapers and reading materials. Brightly colored inspirational sayings fill the walls. Nearby, county employees work in an office area bustling with activity, including someone working the telephone looking for available psychiatric hospital beds around the state.
Another hallway is lined with doors to patient rooms — two to a room — each with plastic book shelves and beds, designed for safety.
Through another locked hallway door is the wing for minors.
A special state waiver allows the county to use four of its 16 beds, if available, for children ages 8 to 18.
“But the unit is teeny-tiny and not an adequate treatment space,” Robin said.
She described the youth area as “nothing more than a couple of bedrooms in a hallway separated from adult services with no recreation space.”
As such, the county can only use the area to stabilize children for “maybe a day or two,” Robin said. Then they must be transferred to psychiatric hospitals better suited for children, such as Aurora Vista del Mar in Ventura, Good Samaritan Hospital in Bakersfield and Aurora Santa Rosa Hospital in Santa Rosa.
Because the PHF doesn’t meet the needs of seniors or kids, those patients usually have to travel hundreds of miles away for care. Some families never seek inpatient care or can’t seek continued care because the distance creates insurmountable problems.
“We know in working with these children and their family members (that) it’s very difficult for families to travel to have to go see them, or figure out how to keep their continued care with their primary care physician here,” said Jill Bolster-White, executive director of the nonprofit Transitions Mental Health Association in San Luis Obispo.
For Paso Robles resident Chris Parker-Kennedy, the lack of local inpatient care had tragic results for her late mother.
Her mother was diagnosed with bipolar disorder in her 40s and had been doing well with treatments until her early 80s when she began to have delusions.
“She was in a state of high anxiety and she felt like she wanted us there all the time,” Parker-Kennedy said. “So I moved her from a big a city to here (where we later found out) there were no support services and a doctor shortage.”
It took awhile to find a local psychiatrist, and even then, they said they weren’t equipped to treat elderly patients with mental disorders, Parker-Kennedy said.
“She died very sad and depressed” in 2012 at age 85, she said. “I feel like if we could have had someone who analyzed her in a hospital setting she would have had a better chance.”
Patients at PHF
In fiscal year 2013-14, the most recent statistics available, the PHF had 1,246 admissions with an average daily patient count of 14 1/2 people.
Robin estimates the county transferred between 275 and 314 patients to out-of-county mental health hospitals statewide annually from 2012 to 2014.
“We put a lot of effort into locating beds,” said Judy Vick, division manager of adult mental health services for the county’s Behavioral Health department. She pointed to a two-page list of hospitals with potential placements that county staff calls daily.
“The transfers out are children, elderly who would be better served in a (gerontology) facility and adults and elderly with private insurance or Medicare,” Robin said. “The PHF keeps adults with Medi-Cal or no insurance. That is our primary population.”
PHF patients generally come from emergency rooms, schools and neighborhoods after being assessed by a county mobile crisis team. Some also come from the courts and County Jail.
A little less than half — about 40 percent — of people who undergo a mobile crisis evaluation remain at their home with outpatient care, Robin said.
No expansion plans
The county has no current plans to expand the 16-bed psychiatric hospital because a 1965 federal regulation doesn’t allow Medicaid (called Medi-Cal in California) funding for inpatient psychiatric hospitals to facilities with more than 16 beds.
The rule doesn’t apply to psychiatric facilities tied to a general hospital, or to patients younger than 22 or older than 64.
The county has applied for a state grant to open a four-bed outpatient crisis stabilization unit in a modular building next to the PHF, where patients could stay for up to 23 hours while they await a bed opening.
The county’s Health Agency provides outpatient mental health services at its clinics and in tandem with nonprofit organizations Transitions Mental Health Association, Family Care Network and Wilshire Health Services.
It also partners with the county’s social services and probation departments, as well as with local schools and colleges.
General county services include medication support through a medical evaluation and ongoing monitoring; individual, group and family therapy; case management; day treatment programs for youth; the 24/7 mobile crisis team; behavioral modification services for youth at risk of losing a home placement; and specialized services for youth involved with the Department of Social Services due to abuse or neglect.
In addition, the Health Agency contracts with:
Transitions-Mental Health Association to provide the SLO Hotline at 800-783-0607 for suicide prevention, information, support and referrals; a treatment team to help clients with medications and health support; and a nurse who helps with medication and health issues for the agency’s homeless outreach team.
Family Care Network to provide mental health care services for children
Wilshire Community Services to provide similar programs for the elderly.
WHO IS ADMITTED TO THE SAN LUIS OBISPO COUNTY PSYCHIATRIC HEALTH FACILITY
The PHF admits four types of patients*:
Those on a 72-hour involuntary hold because they are a danger to themselves or others. (Called a 5150 hold under the state Welfare and Institutions Code).
Those on a 14-day involuntary hold because they are deemed a danger to themselves or others or are gravely disabled. (Called a 5250 hold). This follows an initial 72-hour hold and requires an informal court hearing.
Those who have been deemed gravely disabled due to mental illness under state codes and are awaiting placement at a residential care facility, which may take months.
County Jail inmates who committed misdemeanors and need treatment to restore their competency for court with stays ranging from short visits to a month or more. (Atascadero State Hospital treats felony cases)
* Other patients, including those on private insurance, can go to the PHF for an assessment and then may be referred elsewhere for care. Children and the elderly can be admitted but then transferred due to inadequate space for their age groups.