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Data obtained by Voice of San Diego shows that waits for psychiatric patients to get a spot in long-term care programs are surging, jamming up the entire mental health care system.
San Diego’s psychiatric care system is clogged.
More patients in crisis are pouring into emergency rooms countywide, where they sometimes wait days to move into an inpatient bed in a local hospital. Once they’ve gotten a bed and have stabilized enough to leave the hospital, they wait once more for a spot in a more specialized facility – and those wait times are soaring.
There are essentially three phases of medical care for patients in psychiatric distress: the ER, an inpatient hospital bed where patients are stabilized and post-hospital care where patients receive more specialized treatment.
Hospital data obtained by Voice of San Diego following a public records request shows that waits for a spot in that third phase of care have been surging, wreaking havoc on the entire system.
Adult behavioral health patients with Medi-Cal insurance collectively spent more than 13,200 days waiting in hospital beds regionwide after doctors decided they were ready to be discharged to a lower level of care during an 11-month period between last July and this May, the data shows. That total is already 27 percent higher than the waits reported over a 12-month period just two years ago.
Waits for patients at the county’s psychiatric hospital in Midway were also up 45 percent over the same period.
Waits for post-hospital psychiatric care skyrocketed following an explosion in Medi-Cal enrollment tied to the Affordable Care Act, which went into effect in 2014.
State data reveals more patients are also flooding into inpatient psychiatric units, contributing to the clog and the waits for follow-up care.
There was a 45 percent spike in San Diego County patients transferred from ERs to inpatient psychiatric care between 2008 and 2017, according to data from the Office of Statewide Health Planning and Development.
“Patients are stuck in inpatient beds,” said Dimitrios Alexiou, CEO of the Hospital Association of San Diego and Imperial Counties.
He estimates clearing waits could open up the equivalent of more than three dozen hospital beds a day for psychiatric patients.
Yet hospital executives, county health officials and behavioral health experts say the problem can’t be solved by simply adding more hospital beds for patients grappling with mental health crises.
They also have to confront the shortage of slots in long-term care centers, crisis houses and other temporary or longer-term homes for patients once they leave the hospital.
Scripps Health reports patients have spent as long as 120 days at Scripps Mercy Hospital in Hillcrest as they awaited an opening in one of the county’s long-term care facilities.
The county’s health and human services agency reports that patients waited an average of 61 days last year to get into those facilities.
County leaders have added dozens of new beds in the past year to try to stem the waits.
But county behavioral health director Luke Bergmann said relief has only been temporary, and that waits for patients seeking longer-term care creep back up soon after new beds materialize. Patients move out of the hospital and into care facilities like the Alpine Special Treatment Center in East County where they typically remain for months, clogging the system again.
“As beds fill up, there is still a pipeline of patients coming into acute inpatient care,” Bergmann said.
Meanwhile, hospitals are facing tough decisions as they wrestle with federal and state mandates to upgrade their facilities, and steep financial losses tied to their inpatient units, endangering dozens of the region’s existing hospital beds for psychiatric patients.
Patients stuck waiting are particularly costly for hospitals, all of which lose money on inpatient care.
When a psychiatric patient with Medi-Cal is no longer considered acute, the county’s reimbursement rate for each day of care falls to $697 – less than half of what Alexiou and others said costs hospitals roughly $1,500 a day. The county last year added a $100-a-day patch to the state-set reimbursement rate to lessen the burden on hospitals, but the losses continue.
Those challenges contributed to Tri-City Medical Center’s decision to shutter its 18-bed inpatient unit in Oceanside last year. Now Palomar Health in North County and Scripps Mercy Hospital and UC San Diego Medical Center, both in Hillcrest, are exploring how to sustain their inpatient care as they prepare to replace some of their facilities in coming years.
As hospitals weigh next steps, they are also trying to cope with the unrelenting demand for inpatient psychiatric beds.
A Hospital Association survey and analysis released last fall emphasized the result of the rush of patients seeking inpatient care and waiting for follow-up care: “Adult behavioral health facilities reported being at full capacity and unable to take in new patients an average of 91 percent of the time. Free-standing facilities reported being over capacity several times during the month.”
The revelation that Tri-City would close its behavioral health units last year set off a hail of questions about the county’s stock of inpatient beds and how many are needed to serve the region’s growing need.
By county officials’ count, the region now has 823 psychiatric inpatient beds. The total includes 130 military health system and jail-based beds not accessible to all San Diegans and 66 beds that were recently opened or are scheduled to come online this year.
Exactly how many beds are needed – and whether there truly is a need for more – is up for debate.
About a decade ago, Virginia-based lobbying group Treatment Advocacy Center polled more than a dozen psychiatric care experts who suggested that communities should aim to supply at least 40 to 60 psychiatric beds per 100,000 people.
To achieve that target, San Diego County would have to roughly double its supply of inpatient psychiatric beds.
Many patients, families and advocates argue that the county and local hospitals need to invest in more beds.
Elizabeth Sinclair, director of research for the Treatment Advocacy Center, said the waits patients in San Diego and other communities are experiencing – particularly in local ERs – point to the need for more psychiatric beds.
“The evidence is clear that more beds are needed,” Sinclair said.
But county officials, hospital leaders and even some activists aren’t convinced adding hospital beds is the best antidote.
“Quite frankly, you can add all the beds you want, and you’ll need another bed,” said Shannon Jaccard, who for years led San Diego’s National Alliance on Mental Illness chapter. Jaccard argued that patients are often forced to seek the resources that are available even if they don’t provide the most appropriate care.
Instead, Jaccard believes that a broader, data-focused analysis of the region’s mental-health system is needed.
The county’s behavioral health chief agrees.
Bergmann has said the county first has to study and bolster other parts of its mental-health system, particularly preventative and crisis care that could reduce the demand for inpatient beds.
“I get asked all the time how many beds San Diego County needs and the answer is that we will only know as we begin to invest in chronic care management because good chronic care will reduce the need for inpatient beds and will reduce the need for post-acute step-down services as well,” Bergmann said.
The county has hired a consultant to help it gauge needed additions and changes.
While the county explores next steps, including plans to open crisis centers across the region and to expand post-hospital options for homeless people after they are discharged, patients and families are continuing to grapple with long waits.
The experience is familiar for Melani Bruce, who said she spent six days on a waiting list for a crisis house that could provide up to two weeks of follow-up housing and support as she prepared to leave Sharp Mesa Vista’s inpatient psychiatric unit in December 2016.
The 37-year-old Clairemont resident recalled Sharp Mesa Vista staff telling her to expect a wait. She was thankful to remain hospitalized.
“I didn’t feel safe enough to be on my own outside,” said Bruce, who was battling depression and suicidal thoughts.
Bruce recalled comparing notes with other patients who also sought follow-up treatment programs at the time. Some were homeless. Others were fighting addiction. One man, Bruce said, used a wheelchair and expected a long wait for a longer-term home that could accommodate his disability.
“There were a lot of people there who were waiting,” Bruce said.
After six days, Bruce pulled her name from the crisis house waiting list, and instead enrolled in an outpatient program at Sharp Mesa Vista that she and her doctor ultimately decided was a better fit.
That decision came with a gap in care – and a financial hit.
The outpatient program wasn’t covered by Bruce’s Medi-Cal insurance. Desperate, her parents committed to pay for it. Then, per doctor’s orders, Bruce’s mother Merry Padilla stayed at her daughter’s home the few days before the outpatient session began and in the initial couple days of the program to ensure Bruce wouldn’t be alone after she left the hospital.
Bruce now believes the outpatient program saved her life. She and her mother are grateful she wasn’t forced to languish on a waiting list.
“It’s sad to think that anyone without family to assist would probably just give up,” Padilla said.