By Lisa Halverstadt.
San Diegans grappling with a mental health crisis who need immediate care have long been forced to turn to emergency rooms.
Now, with mental health-related ER visits surging and cutbacks in behavioral health services in North County, county officials want to establish a countywide network of crisis units to stem the rush of patients. They also hope the centers will be more convenient drop-off locations for police who are often tasked with ferrying patients to ERs, a process that can pull them from their beats for hours.
County officials plan to begin in North County, where Tri-City Medical Center last year shuttered its behavioral health hospital beds and a separate crisis unit designed to serve patients for up to 24 hours.
County leaders predict bolstering hospital-based crisis services and opening more community-based crisis units could provide relief for patients, emergency rooms and other mental health services.
Crisis stabilization units are facilities filled with plush recliners rather than beds, where patients can be quickly connected with psychiatric care, medicine and other supports for up to 24 hours.
Sometimes crisis stabilization units are tied to hospitals. Sometimes they aren’t. County officials say they plan to invest in both models.
Earlier this summer, county supervisors voted to expand existing crisis stabilization services at Palomar Medical Center in Escondido, which has seen a spike in mental health patients following the Tri-City closures.
Supervisors also committed to eventually lease or purchase sites for future crisis stabilization services across the county, starting in North County. The county has yet to specify exactly where new crisis units would go or offer a specific timeline to open them. Officials have said they hope to add two new crisis stabilization units in the North County region alone. They are also eyeing the possibility of a crisis unit in Hillcrest, where they are already considering a behavioral health hub.
County behavioral health director Luke Bergmann said the additions could have a game-changing impact on patients whose crises can escalate in ERs.
He estimated that bolstered crisis services could reduce admissions into now-packed inpatient psychiatric facilities by 35 percent to 70 percent.
“(Crisis stabilization units) are excellent and often more humane alternatives and adjuncts to conventional emergency departments, where it’s very difficult to stabilize a patient with a psychiatric illness, which often leads to inpatient admission where otherwise an admission wouldn’t be necessary,” Bergmann said.
Former Alameda Health System psychiatric emergency services director Scott Zeller, who is considered one of the nation’s foremost experts on care models for patients in crisis, said investments in hospital-based crisis units will be necessary to deliver the outcomes Bergmann hopes for.
Zeller, who now helps hospitals design crisis units as a vice president at medical consulting and physician partnership group Vituity, said hospital-based units are better equipped to aid more acute patients than community-based crisis centers.
Zeller was the lead author of a 2014 study published in the Western Journal of Emergency Medicine tracking outcomes for patients on involuntary mental-health holds who were linked with hospital-based crisis services. His study found only about 25 percent of patients who flowed in needed to move onto an inpatient hospital bed.
“Everyone benefits,” said Zeller, who helped design Palomar’s existing crisis stabilization unit.
By comparison, the study noted other research documenting that 52 to 71 percent of psychiatric patients who enter ERs are eventually admitted into an inpatient bed. Patients can also wait hours or even days in busy ERs before they can secure a bed.
But Zeller said his research and visits at units across the country have shown him that community-based crisis units, while helpful, often do not end up having the around-the-clock psychiatry staffing and bandwidth to treat patients with severe mental-health conditions. That means they are less likely to be able to accommodate police officers and to deliver significant reductions in inpatient stays.
“These programs can work if the philosophy is, ‘We’ll take all comers and the only ones we won’t take is people who have [other] medical conditions,’” Zeller said.
The county has yet to detail its model for community-based crisis units, but police agencies are eager to have additional drop-off locations for patients considered a danger to themselves or others.
District Attorney Summer Stephan said police were adamant during two mental-health symposiums she hosted last year that they needed an option other than ERs. Crisis stabilization units were one of primary proposals in the district attorney’s reform blueprint released earlier this year.
“What we hear is sort of desperation because law enforcement is taking them (to ERs) knowing they’re going to wait behind the cardiac arrest and the open wounds and the gunshot, knowing that really that’s not what the person needs,” Stephan said. “I mean, they can tell that the person just needs stabilization for their mental health, but that’s not an option that’s available.”
Rachel Solov, Stephan’s chief of criminal justice and mental health reform strategies, visited facilities in Riverside and Los Angeles to learn more about the model and said she learned some community-based crisis units are well-equipped to take in patients transported by police.
National Alliance on Mental Illness San Diego CEO Cathryn Nacario is also optimistic about the crisis stabilization model. She said community stakeholders are eager to see the county expand on an option that would ideally allow patients and police to walk in and seek help around the clock.
“We have a lot of feedback in the community that we need more of those types of offerings,” Nacario said.
Other stakeholders say they appreciate the county’s plan to better serve patients in crisis but argue the focus also must remain on long-term care options that are fueling waits for both inpatient beds and post-hospital care.
Dimitrios Alexiou, CEO of the Hospital Association of San Diego and Imperial Counties, said crisis stabilization units are likely to better serve patients but that the county must also continue to invest in post-hospital options to address the clogged system they encounter.
“If you don’t have the next service, all of those after it are impacted,” Alexiou said.
Caroline Ridout Stewart, a retired psychotherapist and board president of substance abuse policy reform group A New PATH, said she fears the efforts to pursue the new centers will distract from needed investments in other services, particularly long-term care in the community.
“It has to be part of the solution,” Stewart said. “It cannot possibly be the only solution.”
County leaders say that the planned crisis stabilization investments are part of a more holistic reform effort.
“This work is not about filling gaps in the system,” Bergmann said. “Rather, in order to optimize outcomes and achieve overall cost savings along the way, we need to fundamentally reshape the behavioral health continuum.”