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Crisis Care: The new mental institutions

Sonoma County has a chronic shortage of psychiatric hospital beds. As as a result, a growing number of mentally ill residents are ending up in local emergency rooms and in the jail system. A four-part series, run on four consecutive Sundays, examines the causes and ramifications of the current state of the county’s mental health system, and the people who are impacted the most.

Aug. 6 — Hospitals: The closure of two psychiatric hospitals in Sonoma County has left a gaping hole.

Aug. 13 — Jail: The Sonoma County Jail has become the largest psychiatric treatment facility in the county.

Today — Solutions: Sonoma County explores ways to improve services to people suffering from severe mental illness.

Aug. 27 — Your response: Readers share their stories about Sonoma County's mental health system.

Ongoing coverage: www.pressdemocrat.com/crisiscare

Share your story

We want to hear about your experience with local psychiatric emergency services. What do you do when you or a loved one faces a mental health crisis? Have you or a loved one sat in a hospital bed waiting to be transferred to an out-of-county psychiatric hospital or other mental health facility? Have you or a loved one received psychiatric services in the Sonoma County Jail’s mental health unit? Please send a brief account of your experience to Martin Espinoza at martin.espinoza@pressdemocrat.com.

Over the past decade, Sonoma County has reshaped its approach toward caring for people with mental illness, increasing its investment in community-based outpatient programs while reducing its reliance on psychiatric hospitals.

County officials say they’ve embarked on a new era, one that hopes to fulfill the decades-old promise of creating a safety net of mental health services robust enough to meet the needs of the community.

“We’re headed toward having an integrated system of care, that involves the whole community here in Sonoma County,” said Michael Kennedy, the county’s mental health director. “Mental health and substance use touches everybody.”

The county now spends more than $71 million annually on programs to treat 5,800 people with some form of mental illness, ranging from mild to severe, and assist their families.

It is a fraction of the people who suffer from mental illness in Sonoma County. Nearly 1 in 5 people in the United States have some type of mental illness — and nearly 1 in 25 a serious mental illness, a number that would equate to more than 20,000 people in Sonoma County — according to the federal Substance Abuse and Mental Health Services Administration.

Most never come into contact with the county’s network of mental health services, relying on private insurance and care from family members. Many receive no treatment at all. Critics contend the county’s programs, while effective, do not reach enough people and have long waiting lists.

“Most of those are boutique programs that serve very limited numbers. This is not effective for a county our size,” said Rosemary Milbrath, former executive director of National Alliance on Mental Illness in Sonoma County.

Kennedy said the county is reaching more people now than ever before. A decade ago, the county treated about 3,000 people annually, spending more than $50 million on mental illness, he said.

And it is spending its money more effectively, he said, prioritizing programs that offer a chance of recovery and involve a broad segment of the community, from nonprofits to other government agencies.

About 45 percent of the county’s $71 million budget for mental health services is directed at “community partners,” primarily nonprofits such as Buckelew Programs, which provides housing with support services for mental health patients, including those participating in a court diversion program aimed at reducing the number of mental health patients in jail.

Nearly 15 percent of the county’s budget is spent on patients placed in psychiatric facilities, board-and-care units and state psychiatric hospitals such as Napa State Hospital.

Inpatient psychiatric care is one of the most costly ways to treat people with mental illness, placing huge budgetary pressures on the county, Kennedy said. Over the past two years, the county has seen the cost of providing psychiatric inpatient and long-term care services jump 21 percent, to $10.3 million in the fiscal year that ended in June. It has budgeted $12.3 million this year for such inpatient stays.

Outpatient programs

It is more effective and less expensive to treat people in community-based outpatient programs, Kennedy said.

The county now funds 99 beds in homes with mental health support services and an additional 22 residential beds designed for people facing a short-term crisis. Six additional peer-run respite beds are expected to come online soon.

Such beds are a crucial element of the mental health safety net. Some are used by patients released from a secured psychiatric facility, the county’s psychiatric emergency unit, the jail or a hospital. Others are used by patients who have been granted special probation linked to treatment services.

Seventy percent of these beds have been added since 2004, when California voters passed Proposition 63, which boosted funding for mental health programs by increasing taxes on people earning $1 million or more. Today, the county receives $22 million annually from the tax, or nearly a third of its total budget for mental health services.

Hope House, a 12-bed board-and-care home for men under court-ordered conservatorship with severe mental illness, is a good example of the county’s focus on community-based care. The facility allows people to “step down” to a lower level of care from an inpatient psychiatric unit. Staff are on-site 24 hours a day, seven days a week, to provide intensive care for residents, providing conflict resolution and crisis intervention assistance.

Another program, expected to be launched by January, is designed to offer a route to mental health and housing services that bypasses costly and restrictive crisis stabilization services. The planned Peer Respite Program, staffed by people who are recovering from mental illness, is a community-based, six-bed residence for adults experiencing mental or emotional distress. Nothing like it exists in Sonoma County.

Kennedy said one of the county’s most intensive programs, known as Full Service Partnership, or FSP, is already proving effective at reducing arrests and hospitalizations of those with mental illness. The program, which is budgeted at $7.6 million this year using Prop. 63 money, incorporates an array of services for patients and their families, linking them to mental health services, medical care, education, employment and housing.

The results are promising: Among the nearly 400 people who participated in the program over the last two years, there was an 88 percent reduction in arrests, a 41 percent drop in homelessness and a 42 percent decline in psychiatric hospitalizations, compared to the year before they entered the program.

“Our point is that it keeps people out of homelessness, psychiatric hospitals and the criminal justice system,” Kennedy said.

Diverting from jail

Keeping people out of jail and reintegrating them into the community when they emerge from jail is another focus of the county’s strategy. Key programs include:

— Crisis Intervention Training, or CIT, has taught more than 400 local law enforcement officers the techniques for deescalating encounters with people who have mental illness.

— The Mobile Support Team of mental health workers provides on-the-scene support to law enforcement officers responding to crises in Santa Rosa and Petaluma.

— The Forensic Assertive Community Treatment program, or FACT, offers adult offenders with serious mental illness community-based treatment as an alternative to incarceration. FACT is linked with the probation department and serves about 50 clients at a cost of about $18,000 per client.

— The county probation department has embedded mental health staff who provide substance abuse and mental health services aimed at reintegrating former inmates into the local community.

— The county offers “restoration services” for those deemed incompetent to stand trial for misdemeanor charges who are not in custody.

— The county’s pre-trial services program allows individuals with limited financial means to stay in the community prior to trial so they can continue or begin to receive mental health services outside jail.

The jail itself offers a number of mental health services aimed reducing recidivism for mental health patients. It is the driving principle behind the new $49 million mental health wing scheduled to open at the jail in two years. Current jail programs include substance abuse services, job training and education, parenting classes, and instruction in conflict resolution and anger management.

Easing burden on hospitals

Reducing the burden imposed by mentally ill patients on local emergency rooms is another focus of the county.

In May, the county began conducting medical assessments at its Crisis Stabilization Unit, an emergency treatment center for local psychiatric patients. Such assessments are required before patients can be taken to a psychiatric hospital, such as the ones at Marin General or Aurora Santa Rosa Hospital.

In the past, the county would usually take such patients to Memorial or Sutter hospitals for medical clearance before transporting them to a psychiatric hospital, clogging up their emergency rooms. St. Joseph Health, which operates Memorial Hospital, is providing funding for the assessments.

The program should reduce the need to take mental health patients to local hospitals when they have no physical health issue, said Michael Kozart, medical director for the county’s behavioral health division.

“I think it’s just going to take time for the culture to shift,” Kozart said. “Everyone that comes to us first for medical clearance is one less person going to the ER.”

Forming partnerships between the county, local nonprofits and health care providers has been a priority for Kennedy since he joined the county’s mental health division in 2001. Back then, the county spent 80 percent of its mental health budget on direct services and 20 percent on services provided by outside contractors. “Today, it’s 50/50,” he said.

Barbie Robinson, head of the county health department, credits Kennedy with the shift toward a community-based approach to mental health care.

“It speaks to Mike’s leadership and vision and direction,” she said.

This report was produced as a project for the California Health Journalism Fellowship, a program of the Center for Health Journalism at the USC Annenberg School of Journalism. You can reach Staff Writer Martin Espinoza at 707-521-5213 or martin.espinoza@pressdemocrat.com. On Twitter @renofish.

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