When a psychiatric patient shows up at the emergency room at Santa Rosa Memorial Hospital, the staff quickly removes anything dangerous before placing them in a treatment room.
Cables and heavy objects are stowed away. A cart with essential instruments — scalpels, needles, sutures and commonly used drugs — is wheeled out.
“Anything that they could reach comes out of the room,” said Marirose Apolinarski, director of nursing in Memorial’s emergency department.
A “sitter” or security guard is placed near the doorway to watch over the patient 24 hours a day. If the patient can’t be managed with medication, they are restrained to prevent them from harming themselves or others.
This scene is repeated more than six times a day, on average, at Memorial — Sonoma County’s largest hospital — which logged nearly 2,500 encounters with psychiatric patients in its emergency department last year. Most will sit in an emergency room for hours, though their stays often turn to days, weeks, and in some cases even longer.
Their physical ailments, if they had any to begin with, are addressed promptly, but their mental health — their mood or personality disorder, neuroses or extreme psychosis — is left untreated. They wait in a kind of limbo for something in short supply for low-income residents in Sonoma County: a bed in a psychiatric hospital.
Increasingly, the burden of caring for people with severe mental illness is falling on local hospital emergency rooms and the county jail. Both are ill-equipped to handle the volume of mental health patients they are encountering, creating bottlenecks that are deeply and broadly felt by all residents, The Press Democrat found during a six-month review of Sonoma County’s psychiatric emergency services.
“Even if you don’t care about the human rights side of the issue, this is a hugely expensive and inefficient way to provide care,” said John Snook, executive director of the Treatment Advocacy Center, an Arlington, Virginia, nonprofit that works to eliminate barriers to treatment for people with severe mental illness.
Access to inpatient treatment is critical for people experiencing a severe mental illness, estimated at about 4 percent of the U.S. population — a figure that would equate to more than 20,000 people in Sonoma County.
But mental health beds for low-income residents have become much harder to find on the North Coast since the closure in Santa Rosa of two psychiatric hospitals, both shuttered 10 years ago for financial reasons.
Much has been done over the last half-century to break down the old institutional psychiatric treatment models that saw those with mental illness cast into state-run asylums indefinitely. The goal was laudable: to improve treatment by bringing those with mental illness into the fold of American society, into our communities.
Mental health advocates, however, agree that goal was never fully realized — and some argue it has in many ways harmed those with the most severe mental illnesses. Increasing resources for outpatient care has been accompanied by a reduction in the number of beds in hospitals that specialize in treating people that need it the most.
The Press Democrat review included an analysis of local hospital and jail data, a survey of state and national research on mental health, and interviews with dozens of people with mental illness and their family members, government officials, hospital administrators, jail commanders and local and national mental health advocates.
The review found:
— As recently as 11 years ago the county had 60 psychiatric beds at two hospitals for low-income adults covered by Medi-Cal. It now has none. As a result, hundreds of patients with severe mental illnesses are sent to facilities outside the county, often after lengthy waits in hospital emergency departments or regular inpatient rooms, released into the community, or worse, wind up in jail.
— Local residents experiencing psychotic episodes are becoming a significant and regular burden on clogged hospital emergency departments, slowing down treatment of people in the ER with traumatic injuries, severe illnesses and other noncritical ailments. At Sutter Santa Rosa Regional Hospital, psychiatric patients take nearly three times as long to get through the emergency department as patients with physical conditions. These patients routinely take up 25 percent of the beds in the emergency department, even though they comprise only 5 percent of the patients seen in the ER.
— The county jail has become the largest psychiatric treatment facility in the county. The number of inmates suffering moderate to severe mental illness has doubled since the closure of the county’s two psychiatric hospitals 10 years ago, even as the jail population has remained relatively stable. To provide more appropriate care for those with serious mental illness, the county is building a nearly $49 million mental health facility at the jail. It will cost $5.5 million annually to operate.
— Although the county is home to a relatively new 95-bed psychiatric hospital in west Santa Rosa, federal funding policies have essentially put the facility beyond the reach of low-income residents between the ages of 21 and 65 because Medicaid — the federal program that covers care for most poor and disabled patients — will not pay for their treatment.
— The county now spends $66 million annually on treating people with mental illnesses, providing an array of services from housing assistance, case management and medication support to operating the equivalent of an emergency room for mental health patients in crisis. But mental health advocates argue that a shortage of inpatient treatment has left many suffering severe mental illness without access to proper care during moments of crisis.
Hospitals and the people they serve — those with and without mental illness — are negatively impacted.
“It’s just an unwinnable situation,” said Sheree Lowe, vice president of behavioral health for the California Hospital Association, a trade group that represents more than 400 hospitals and health systems in California. “Unfortunately, it’s the consumer that’s left in the lurch.”
Nearly 1 in 5 people in the United States suffers from some type of mental illness — and nearly 1 in 25 from a serious mental illness — according to the federal Substance Abuse and Mental Health Services Administration.
The estimated 20,000 Sonoma County residents with serious mental illness live among us, whether in group homes with their peers, in houses with their families or on the streets. Many exist peacefully without coming into contact with law enforcement. But when they are in severe crisis — and, more importantly, require long-term care — major problems arise.
Michael Kennedy, the county’s mental health director, defended the local system of community-based care as an effective alternative to the bygone era of state-run asylums and large, hospital-run psychiatric units. They say recent years have proved the system is working and that more services are needed, particularly long-term supportive housing and crisis residential programs, which offer the most immediate alternative to a secured psychiatric unit.
“Law enforcement likes to act like everybody winds up with them — and they don’t,” Kennedy said. “There’s a lot of mentally ill folks in our county that live with their families and they don’t have much interaction with law enforcement.”
But critics are not convinced. They draw a direct correlation between the decline in psychiatric beds and the increase in the number of jail inmates with mental illness, concluding the county does not have enough facilities to treat people with severe mental illness.
Nowhere to go
Russell Becker, 49, stands in the middle of a room at a Santa Rosa wellness center for people with mental illness, his black athletic pants and underwear dropped to his ankles as he points to a geography of scars and skin grafts on his torso, legs and arms.
Becker, who torched himself with gasoline more than six years ago in Texas, said he has schizophrenia and bipolar disorder. A voice he describes as that of an older male, deep and low, can put him “way out there,” in an uncontrollable manic state, as if he were binging on speed.
Last fall, Becker, who is often homeless, called police after someone stole his medications while he was at Resurrection Church in west Santa Rosa. He said he was threatening suicide, again “hearing voices saying set myself on fire.”
That triggered an involuntary psychiatric hold and a trip to Sonoma County’s relatively new Crisis Stabilization Unit, or CSU, a sort of emergency department for psychiatric patients in west Santa Rosa. The county-funded unit, designed to reach full capacity at 30 beds, offers up to 23 hours of intensive treatment for adults and youth, and provides referrals to local residential crisis treatment programs and secured psychiatric hospitals outside the county.
Becker said he spent two weeks at CSU, waiting for a bed to become available at a local residential program. He said he asked to be sent to the psychiatric unit at Marin General Hospital in Greenbrae, but county mental health staff refused because they thought he was “drug-seeking” pain medications. After two weeks, he was released with a referral to a board-and-care home, but he said he was turned away because he smoked medical marijuana.
The county funds an array of mental health services — a mental health court and diversion program, crisis intervention training for law enforcement, a mobile support team and crisis or long-term residential treatment. But it cannot provide Becker and others like him the one thing mental health advocates say Sonoma County, like the rest of the country, badly lacks: a bed at a facility that specializes in psychiatric care.
Aurora Santa Rosa Hospital, a private psychiatric facility, opened in 2013 at the site of Memorial Hospital’s shuttered Fulton Road mental health hospital. It has just under 100 beds, but it is usually not an option for people like Becker because Medicaid will not reimburse treatment for most adults there.
The county’s CSU, on the other hand, is designed to treat psychiatric emergencies on a short-term basis, acting like a medical emergency department. Patients are first stabilized and then a determination is made whether to send them to a psychiatric hospital or to release them to the community if they are well enough.
The options were not always so few.
Low-income patients left out
Back in 2006, the county had 60 psychiatric beds available for low-income residents. The first, the county-owned Norton Center, was operated by Sutter Health and had 30 beds. It was reduced to half that capacity just before the Chanate Road facility closed in 2007. The second, operated by Memorial Hospital at a satellite facility on Fulton Road in west Santa Rosa, was staffed for 30 beds in 2006 and reduced to 18 beds when it closed in 2008.
The closures were driven by high operating costs and the hope that community-based mental health programs had rendered the hospitals obsolete.
Their departure left essentially no inpatient psychiatric beds available in the county for low-income adults, a trend that is becoming all too common throughout California and the United States. In fact, 25 counties in California have no inpatient psychiatric services, according to the state hospital association.
Lake and Mendocino counties are among those 25, as are most counties further north.
Although Sonoma County has 95 psychiatric beds at Aurora, those beds are out of reach for most adults because of Medi-Cal funding restrictions.
The California Hospital Association, citing expert studies, said about 50 mental health beds are needed per 100,000 individuals — depending on the availability of appropriate outpatient services — to meet the current need for psychiatric hospitalizations.
By that standard, Sonoma County should have about 250 mental health beds. Even if Aurora could be reimbursed for treating low-income Medi-Cal patients, the county would still fall more than 150 beds short of the hospital association’s goal.
“People need to wake up. There is no other illness where we would allow people to just die with their illness,” said Rosemary Milbrath, former executive director of the National Alliance on Mental Illness Sonoma County. “We wouldn’t allow people to go into diabetic comas, to have heart attacks on the sidewalk.”
Sonoma County is not alone in what mental health care advocates have called a national crisis. In the more rural communities of Northern California, the situation is even worse.
D.J. Jaffe, a national advocate for those with severe mental illness, said most county mental health programs target those with milder forms of mental illness, such as minor depression, anxiety and adult attention-deficit/hyperactivity disorder. Those with serious mental illnesses, such as schizophrenia and bipolar disorder, are increasingly the responsibility of county jails and hospital emergency rooms, he said.
Jaffe, executive director of Mental Illness Policy Org.and co-founder of the Treatment Advocacy Center, says the nation has traded psychiatric beds for jail cells and emergency rooms, where treatment cannot be denied.
“State hospitals are closing so the jails are opening forensic wings,” Jaffe said. “Sheriffs are the ones demanding change, it’s not the mental health industry. They get mental health dollars without any obligation to help the severely mentally ill.”
Public beds go private
No one set out to make Sonoma County emergency rooms, jails and homeless encampments the new asylums. Advocates like Jaffe and Milbrath argue that, as with many other counties across the nation, the rise of the community-based mental health model in Sonoma County simply did not meet the needs of those with severe mental illness.
When Norton closed in Santa Rosa in June 2007, the county had been paying about $10 million over a five-year period to cover the difference between the cost of patient care and the reimbursement Sutter got from Medicaid, Medicare and private insurers.
Memorial Hospital’s losses were even greater at its Fulton Road psychiatric unit, which had 80 beds when it opened in 1990. When it closed, St. Joseph Health said the unit had lost nearly $22 million during the preceding three years.
Sonoma County Supervisor Shirlee Zane, a vocal critic of private mental health care, said psychiatric illnesses should be treated no different than physical ones.
“It’s a civil rights issue, it’s discrimination,” said Zane, whose late husband suffered from mental illness before he took his own life in 2011. “We have years and years of private health care not treating mental illness on an equal basis, discriminating against people with mental illness.”
She said taxpayers are now having to pay for that service through emergency psychiatric services and local jails.
She and other mental health advocates say the shortfall should have been resolved with the passage of a federal law in 2008 that requires insurance companies to cover mental health care to the same degree as physical health care. But the federal government, she said, has failed to enforce the law, called the Mental Health Parity and Addiction Equity Act.
Emergency rooms, on the other hand, have no choice but to treat all who walk through the door.
Under a 1986 federal law, the Emergency Medical Treatment and Labor Act, anyone who walks into a hospital emergency department is entitled to treatment, regardless of their ability to pay. But hospitals were left to figure out how to pay for it.
In the case of jails and prisons, inmates have a right to medical and mental health treatment under the 8th Amendment of the U.S. Constitution, which forbids cruel and unusual punishment.
Both hospital and mental health advocates agree that treating mental illness in emergency departments is expensive, inefficient and causes bottlenecks in the flow of patients through the ER. Repeated hospital readmissions of those with mental illness is another big problem, said Snook of the Treatment Advocacy Center.
Snook cited a 2014 study by the federal Agency for Healthcare Research and Quality that examined hospital readmissions within 30 days. The study found Medicaid patients with mood disorders, schizophrenia and diabetes, respectively, had the largest number of readmissions, resulting in about $839 million in hospital costs in 2011.
Snook also pointed to a 2015 survey by the American College of Emergency Physicians, which found that inadequate inpatient psychiatric treatment was leading to more psychiatric patients in emergency departments waiting longer to see a doctor. Nearly 90 percent of emergency physicians reported that patients were being “held” in emergency departments, a practice known as “boarding,” because a bed at a psychiatric hospital was not available.
The survey found that boarding led to distracted hospital staff, bed shortages for nonpsychiatric patients and instances where patients with mental illness often become distressed and violent because of delays in treatment.
General acute care hospitals were not designed or equipped to provide that level of care in their emergency departments, said Lowe of the state hospital association.
“How we can feed people three times a day, provide showers, visiting and sleep environments that emergency departments were never designed to do?” she said.
Mental health patients have a disproportionate impact on hospital services because they stay in the hospital longer, said John Stein, medical director for the emergency department at Sutter Santa Rosa Regional Hospital.
Last year, the emergency department at Sutter Santa Rosa Regional Hospital treated 957 psychiatric patients for a total of nearly 7,321 hours, according to hospital records. That’s a 15 percent increase in the number of patients seen during the same period in 2015, when the hospital saw 834 mental health patients in its emergency department.
Each psychiatric patient stayed in the emergency department for an average of 6.5 hours, compared to an average stay of 2.5 hours for all other patients.
The impact on hospital operations is felt by all who use the emergency department, Stein said.
“In fairness, the way that it plays out mostly is that we stack patients in the waiting room,” he said, adding that many psychiatric patients do not need any sort of physical medical treatment. When that happens, he said, “we don’t have room for the ones that always do need medical care.”
The loss of psychiatric beds has a broad and generalized impact on local communities, Lowe said.
“Individuals are being incarcerated. They are deteriorating and decompensating,” she said. “I think it has increased our homeless population. It further stigmatizes individuals with a mental illness. It’s severely impacting our social service programs at the local level.”
Across California, the figures show a worsening situation, with a growing population in need of mental health care and public and private sector efforts falling short of the demand.
Out of 14 million annual emergency department visits statewide, more than 1 million involved treatment of people with a behavioral health issue, Lowe said, citing analysis of a report by the hospital association commission in 2013.
According to the association’s most recent assessment of psychiatric hospital beds, the state has lost 44 mental health facilities and 30 percent of its bed capacity, or 2,800 beds, since 1995.
For several years, county officials and mental health advocates have been looking for ways to both keep psychiatric patients out of emergency departments and jails — in effect, making good on the promise of community-based treatment that was used to justify the closure of psychiatric hospitals over the past half-century.
These steps include establishing more residential housing with supportive mental health services in Sonoma County. In addition, there are efforts to create a small, freestanding psychiatric facility that qualifies for Medicaid funding, and build a farm-based mental health community in the region.
Back at the peer-run Wellness and Advocacy Center, a nonprofit program operated by Goodwill Industries, Becker meets with other mental health patients, sometimes volunteering. He is on a number of medications, including trazodone, seroquel, klonopin and methodone, prescriptions meant to help his schizophrenia. He said he was sexually abused as a child and at 13 started using methamphetamine, drug use that he says “created” his schizophrenia.
The wellness center is located in a drab, aging building off Chanate Road, just east of the former Norton Center, the county’s shuttered inpatient psychiatric hospital, and the now mothballed Sutter Medical Center.
The entire complex is being sold to a private developer who wants to build up to 800 units of rental housing.
But Becker sees a greater need in the area for mental health services, including an inpatient facility, a larger wellness center, a day treatment program with art and trades classes where people can learn self-sufficiency and skills to cope with their illnesses in a positive way.
“I’ve thought about going in there and squattin,’ ” Becker said. “Right now, going in there and squattin’, just get several people and go in there and take over Sutter hospital.”
You can reach Staff Writer Martin Espinoza at 707-521-5213 or firstname.lastname@example.org. On Twitter @renofish.