24 MONTEREY COUNTY WEEKLY april 6-12, 2023 www.montereycountyweekly.com (Those numbers exclude beds at the state’s five psychiatric hospitals, which care for court-ordered patients, 90 percent of whom come to them from the criminal justice system.) Over half the counties have no acute beds and most have no beds for children and teens. Separately, the state is short of nearly 3,000 community residential beds— usually in homes and small facilities that provide a room, meals, medication and other support services for people who do not need 24-hour nursing care, according to the study. Monterey County has 40 acute psychiatric care beds, located at CHOMP and Natividad—the hospital run by Monterey County—with 18 and 22, respectively. As of now, Monterey County has none for children and teens. Dr. Christopher Burke at Natividad says they usually have a psychiatric bed available for a patient who arrives in crisis, but if not, the calls to other facilities in the state begin. “The big crisis for us is the lack of child and adolescent beds,” he says. “Those are often very sad cases and difficult to care for.” The county is set to get its first in-patient facility for youth with 16 beds and an outpatient wing. The outpatient wing is set to open this fall, and the residential beds in early 2024. Ohana, as it was named, currently operates as an outpatient program of Montage Health, the nonprofit parent company of CHOMP. A permanent home is under construction in Ryan Ranch in Monterey. It was made possible by what was the largest donation in Montage’s history in 2018 by Roberta “Bertie” Bialek, $105.8 million, to build a mental health treatment center just for children and adolescents. (Bialek is sister to Warren Buffett and was an early investor in his company.) She named the future facility Ohana, the Hawaiian word for “family.” Another facility for children and youth recently broke ground in Santa Clara County, but statewide there are only 746 psychiatric beds in 16 counties for minors (see sidebar, p. 30). That is despite a growing need and a severe shortage of outpatient services. How California got to this point goes back decades to the late 1950s and early 1960s, when deinstitutionalizing psychiatric patients became a cause for advocates and elected officials. It was partly brought on by the introduction of the drug Thorazine, which allowed some patients to live independently outside of a locked psychiatric hospital, according to a report by CalMatters. In 1967, then-governor Ronald Reagan signed into law the Lanterman-PetrisShort Act, which essentially ended hospitalizing people against their will except in extreme cases where they are a danger to themselves or others or “gravely disabled,” the ones that are treated long-term in state hospitals. The overall theory at the time the LPS Act was passed was that people in psychiatric hospitals could receive individualized treatment in facilities located in their communities. The problem was that community facilities were not built as deinstitutionalization unfolded. In large part, it boils down to money. Thanks to state and federal laws that dictate how mental health care providers are reimbursed for care, opening a facility or expanding an existing one are losing propositions, according to Dr. Emily Wood, a Los Angeles child and adolescent psychiatrist and the government affairs chairperson for the California Psychiatric Association. The reimbursements don’t begin to cover the actual costs of keeping a bed in operation. Over the decades since LPS the hospitals with psychiatric beds have shut down. “And now we’re saying, oh gosh, we needed those,” Wood says. The problem of too few beds goes beyond just money, she says, because it also includes not using existing beds in an efficient way. There are those patients who are considered for conservatorship—a court-ordered process for determining the vulnerability of someone who might not be able to care for themselves—that are housed in acute beds for up to eight months when they could be stabilized within a month and then cared for in a stepdown facility providing less intensive care. The result, Wood says, “is we have people in hospitals who shouldn’t be there.” Meanwhile, the need within the general population for psychiatric services is growing, compounded by the pernicious problem of substance abuse. The RAND study found the need for psychiatric beds in California may only increase by a modest 1.7 percent through 2026. However, there is a general consensus that the overall need for greater mental health services and professionals is growing at a much higher rate. Walk-in patients to the emergency room at SVH start at outdoor tents that were erected at the start of the Covid-19 pandemic. Here, patients are evaluated for respiratory illnesses and triaged by severity of illness or injury. Some are treated in the tents and released. More acute patients are taken inside to a bed. The reality is that Salinas’ growing population—14,000 when the hospital was built in 1950 and 60,000 when it expanded in 1974—has outpaced the hospital’s capacity. Now with over 160,000 residents and more than 53,000 ER visits in 2021, SVH’s 16 beds aren’t enough, Singh says. The hospital needs at least 44 to meet the community’s needs, from minor infections to major accidents. Someone who arrives at SVH in a severe mental health crisis, especially if they want to harm themselves, is taken inside to an ER bed. Mental health visits only constituted 2.4 percent of ER patients in 2021—1,224 total mental health visits, with 38 of those transferred to psychiatric beds elsewhere—but Singh says those patients require more time and resources. First, staff look for life-threatening issues and make sure the patient isn’t overdosing on a drug. Once they’ve made sure a patient with mental health needs is medically stable, they begin to assess whether they need inpatient care or might do well with outpatient care. That takes time for which there is no quick fix, he says: “You have to slow down and act compassionately.” Meanwhile other patients with physical issues might be waiting for their turn. “We really try to use those beds as well as possible for the needs of our community while trying our best to address mental health needs,” Singh says. “It does stress the system [and takes] a bed out of the system and we cannot use that bed for another patient. It does wind up limiting our capacity in the ER, but we work “This is the next step in our transformation of how California addresses mental illness.” (Pictured right) Dr. Singh enters a room to see a patient. (Left) Dr. Singh confers with staff members. Daniel Dreifuss Daniel Dreifuss
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