Cares Crisis Residential North An Underutilized Mental Health Asset

Conclusions 3

• CL1
  When Emergency Room physicians are not provided the patient’s mental/medical history, they are reluctant to sign a patient’s admission package to CARES Crisis Residential North.
• CL2
  CARES Crisis Residential North is a safe environment for patients discharged from a locked facility to transition back into society.
• CL3
  Telecare Corporation appears to be operating an efficient and effective program for aftercare of recovering mentally ill patients. The 2011-12 Santa Barbara County Grand Jury was favorably impressed by CARES staff, program and facility. The Jury encourages full utilization of this unique asset. Telecare and Alcohol, Drug and Mental Health Services need to aggressively inform those who could refer patients to this facility of the advantages of doing so. Santa Barbara County Grand Jury 5 CARES CRISIS RESIDENTIAL NORTH FINDINGS AND RECOMMENDATIONS Finding 1a CARES Crisis Residential North, with a 12-bed capacity, has averaged 7.4 full beds in the last five months through March, 2012. Finding 1b The Santa Barbara County medical community is not fully aware of the capabilities of CARES Crisis Residential North and its benefit to recovering mentally ill patients. Finding 1c CARES Crisis Residential North is the only unlocked facility for mentally ill patients who have no insurance in both Santa Barbara County and San Luis Obispo County. Finding 1d CARES Crisis Residential North helps mentally ill indigent patients obtain food stamps and Medi-Cal insurance; as well as helping them find homes and jobs. Finding 1e Utilization of the CARES Crisis Residential North facility has been shown to be a cost effective treatment option for Santa Barbara County post-acute mentally ill patients. Recommendation 1a That the Mobile Crisis Team and CARES Crisis Residential North develop and coordinate an outreach program with providers of services to the mentally ill on the capabilities of CARES Crisis Residential North for possible placement of their appropriate patients. Recommendation 1b That Santa Barbara County Department of Alcohol, Drug and Mental Health Services coordinate with the San Luis Obispo County Psychiatric Health Facility on the unoccupied bed capacity of CARES Crisis Residential North for possible placement of appropriate patients. Finding 2 When Emergency Room physicians are not provided the patient’s mental/medical history, they are reluctant to sign a patient’s admission package to CARES Crisis Residential North. Recommendation 2 That the Mobile Crisis Team and CARES Crisis Residential North work with Emergency Room staff to facilitate a protocol for admitting their patients to the transitional CARES program. . 6 Santa Barbara County Grand Jury CARES CRISIS RESIDENTIAL NORTH Finding 3 CARES Crisis Residential North is a safe environment for patients discharged from a locked facility to transition back into society. Recommendation 3 That CARES Crisis Residential North coordinate with the Santa Barbara County Main Jail/City Jails and the Santa Barbara County Psychiatric Health Facility on the capacity of CARES Crisis Residential North for possible placement of their appropriate patients upon release. REQUEST FOR RESPONSE In accordance with California Penal Code Section 933.05, each agency and government body affected by or named in this report is requested to respond in writing to the findings and recommendations in a timely manner. The following are the affected agencies for this report, with the mandated response period for each. Santa Barbara County Department of Alcohol, Drug and Mental Health Services – 90 days Findings 1a, 1b, 1c, 1d, 1e, 2, 3 Recommendations 1a, 1b, 2, 3 Santa Barbara Psychiatric Health Facility – 90 days Finding 3 Recommendation 3 Santa Barbara County Sheriff – 60 days Finding 3 Recommendation 3 Santa Barbara County Probation Department – 90 days Finding 1b Recommendation 1a Santa Barbara County Grand Jury 7

Observations 6

• OB1
  Must not be combative or medically compromised
• OB2
  Must be ambulatory and stable on their medication
• OB3
  Must be referred through ADMHS agencies
• OB4
  Must be referred by a physician
• OB5
  Must want to come to the facility
• OB6
  Must be adults Santa Barbara County Grand Jury 3 CARES CRISIS RESIDENTIAL NORTH A referral for admission can be made by health services (Corizon) at the County jail, staff at the PHF (a 16-bed, locked involuntary mental health facility) or Vista Del Mar (also an involuntary facility) in Ventura County. Vista Del Mar is a contracted facility where Santa Barbara County patients are housed due to a shortage of acute beds. The Crisis Team may also conduct an assessment and make an admission recommendation. Following the Crisis Team’s recommendation, an examining physician, often at an Emergency Room, must fill out a 10-page admissions application. The process requires documentation of the patient’s medical history from several sources. Some of the patient’s medical history may not be available to the Emergency Room physician. Unfortunately, the admissions form is mandated by the State, therefore CARES is required to use it. Over the past three years the admissions package has been reduced, but it is still formidable. Administrators of the ADMHS, PHF, Vista Del Mar, the Mobile Crisis Teams and CARES confer through a daily conference call at 10:30 each morning. The Jury was told that each patient’s condition is evaluated and decisions are made on patient services, discharge plans and level of care. Additionally, the availability and locality of beds is discussed. The Jury was puzzled that so few patients moved from the acute facilities to the stabilizing aftercare program at CARES. Usage While conducting its investigation, the Jury was provided differing information concerning utilization. According to ADMHS, over the past few years, the annual average occupancy of the 12-bed facility has ranged from 7.0 to 8.6 beds per day. Telecare’s usage data also shows consistent underutilization. Its Statement of Work states it will serve approximately 625 adults recovering from a mental health crisis annually. The actual number in 2010-11 was only 322 or 51 percent of the planned participation. On only two days in early 2012 have all beds been filled. Figures from Telecare show the following average daily bed occupancy: November 2011 9.7 December 2011 5.8 January 2012 7.5 February 2012 5.5 March 2012 8.5 Mentally ill patients who are in crisis (Section 5150 of the California Welfare and Institution Code) are admitted to the PHF where patients are stabilized until they are no longer a danger to themselves or others. Once stabilized many of these patients benefit from continued care to further support their recovery as envisioned by the 2004 community roundtable. The Jury was also told ADMHS does not do outreach. The Probation Department only became aware of the program within the past year, and has made its first referral. The first two referrals from Cottage Hospital are also recent. When questioned, a Crisis Team spokesman responded that Emergency Room physicians, many of whom are new, are not 4 Santa Barbara County Grand Jury CARES CRISIS RESIDENTIAL NORTH aware of CARES capabilities. Other outreach possibilities include areas in San Luis Obispo County which are in close proximity and currently do not have such a facility. The Jury believes that if other County mental health agencies were made aware of CARES capabilities, the usage would increase, benefiting both the patients and the County. Finances The contract with CARES has two parts. There is a fixed portion, as the facility must operate 24/7/365 even if only one bed is occupied. There is a variable portion based on the number of bed days occupied. The variable portion of the contract is renegotiated at the end of the fiscal year based on the number of bed days of the previous year. For fiscal year 2011-12, the fixed costs were projected to be $81,6l8 and the variable costs were $891,681 for a total cost of $973,299. Because of the variable cost component, the Jury determined that the County receives a partial rebate based on the number of unused beds from the previous year. According to ADMHS, the cost for operating CARES has decreased to a bed-day cost of $378. The bed-day cost of the PHF is $1,214. If the 16-bed PHF is fully occupied, patients are sent to Vista Del Mar in Ventura, at a cost of $748 per day. ADMHS can recover 50 percent of the costs of Medi-Cal patients in either the PHF or CARES, but not for patients at Vista Del Mar. There is no recovery of costs for non Medi-Cal patients, and the Jury was told it is difficult to get this population served. When an indigent patient is admitted to the PHF, staff makes every effort to get the patient qualified for government help. The Jury was also told it can take up to six months for this to happen, and that most applicants are denied on their first application, usually because they have no permanent address. However, CARES accepts all appropriate referrals, regardless of ability to pay. It is the only aftercare facility to do so. Responding to a 2010-11 Santa Barbara County Grand Jury report, Homeless Mentally Ill Indigent Recidivism, the County’s Executive Office investigated the cost of incarceration vs. the cost of supportive services for the homeless mentally ill. The investigation found it costs $44,572 per year for incarceration, but would cost only $33,560 a year to provide support services for the mentally ill. The Jury believes maximum use of the CARES facility could reduce costs for the County.

Agency Responses 2

Government agencies' official responses to this report's findings and recommendations. Click on a response to see the structured breakdown.