Gran Jurado del Condado de San Luis Obispo
2022-2023
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Hallazgos & Recomendaciones
12 hallazgos
F1:
All high schools investigated by the Grand Jury are aware of and acknowledge mental health concerns and are commended for seeking to address this need.
Recomendaciones relacionadas (1)
R1:
The San Luis County Office of Education (SLOCOE) should develop a plan to assist schools and districts in obtaining grants for funding of Wellness Centers within the 2023- 24 school year.
F2:
There is a growing trend in establishing Wellness Centers on campuses. Wellness Centers are seen as a best practice, shifting the tone and culture of the school to a more positive atmosphere in support of mental health.
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R2:
School administrators need to extend the mental health curriculum beyond the Freshman health class within the 2023-24 school year.
F3:
Freshman Health Class curriculum has a specific mental health section, whereas additional instruction at higher grade levels is inconsistent among Districts.
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R3:
In keeping with the SLOCOE mission statement, transition from a supportive position to a more proactive leadership role in expansion of best practices for mental health across County campuses is needed.
F4:
School Districts have different approaches to address mental health and there is no uniformity.
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R4:
Utilize more externally developed programs to maximize mental health and substance abuse prevention, i.e., FNL, Red Ribbon Week, and Every 15 Minutes.
F5:
Significant strides are being made to destigmatize Mental Health among the student population.
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R5:
More campus staff and teachers need to be trained in Youth Mental Health First Aid or an equivalent program within the next school year.
F6:
There is a lack of front-line staff training in mental health intervention.
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R6:
Work toward a full time SRO at all high schools.
F7:
SRO staffing is inconsistent among the school districts.
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R7:
Where possible, employ full-time permanent mental health staff at every high school.
F8:
School districts are having difficulty hiring trained and certified staff for mental health. Contract staff are often used part-time. As a result, access for students can be insufficient and inconsistent.
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R8:
Provide widespread training of campus staff on Narcan use within the 2023-24 school year.
F9:
Roles of counselors vary among schools. Not all counselors have defined roles pertaining to mental health.
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R9:
All campuses should make an anonymous bullying reporting program available within the 2023-24 school year.
F10:
Insufficient staff have training on how to use Narcan for possible opiate overdoses.
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R10:
Suicide awareness training needs to be conducted annually for teachers, staff and students.
F11:
Bullying reporting methods should be more extensive and wide-ranging. Bullying tiplines does not appear to be anonymous at all schools.
F12:
Suicide prevention programs need to be more consistent and robust on high school campuses.
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Hallazgos & Recomendaciones
13 hallazgos
F1:
In the West Facility, facilities E, F and G are scheduled for closure by November 6, 2023. Facility M, which houses inmates trained to fight wildland fires throughout California will remain open.
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R1:
Improve barriers and security between the Oklahoma Safe Parking Site and the Honor Farm by end of December 2023. SAN LUIS OBISPO COUNTY CORONER’S FACILITY
F2:
There are a number of notable, successful programming opportunities that serve inmates by preparing them with life skills to be productive members of our community. SAN LUIS OBISPO COUNTY JAIL
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R2:
Consider increasing the number of Employee Assistance Program (EAP) visits for trauma fatigue and mental health wellness support for staff by end of December 2023.
F3:
The location of the Oklahoma Avenue Safe Parking Site next to the Honor Farm creates a safety hazard to inmates and staff. Materials – including illegal substances, drug paraphernalia, and human waste -- have been tossed over the fence from the Safe Parking Site, landing within the confines of the Honor Farm.
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R3:
Hire a full-time Medical Examiner and additional support staff as required to manage ongoing case load by end of March 2024.
F4:
Honor Farm programs are operating at minimal levels due to the current low inmate population, and there are no employees available to supplement the staffing due to staffing challenges throughout the county.
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R4:
Increase the number of Narcan units on site and develop an inventory checklist and procedure for monitoring medication expiration dates by October 1, 2023. SAN LUIS OBISPO COUNTY CRIME LAB
F5:
Jail management has successfully managed the COVID-19 pandemic through staff and inmate education and vaccination, resulting in an eradication of active cases within the jail. SAN LUIS OBISPO COUNTY JUVENILE HALL
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R5:
Identify area in facility where staff can have break room by end of December 2023. SAN LUIS OBISPO COUNTY PROPERTY ROOM
F6:
There is an ongoing staffing challenge due to a 22% reduction in applicants since 2016, exacerbated by the pandemic while occupancy rate of juveniles has remained stable
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R6:
Follow through on property room climate control enhancements.
F7:
The labor-intensive programs appear successful in thwarting recidivism among the juvenile residents. CITY POLICE AND COUNTY COURTHOUSE HOLDING CELLS
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R7:
Does this healthcare award include mental health services?
F8:
Despite waiting on progress by the State to build a new courthouse, the current holding cells are functioning well and meeting the needs of the inmate population. SAN LUIS OBISPO COUNTY CORONER’S FACILITY
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R8:
What is the percentage of mental health patients coming into the jail? Is this an increase or decrease relative to recent years?
F9:
Physical space is limited impacting the overall work atmosphere. Recent improvements to the autopsy suite have made it fully functional.
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R9:
What is the interaction/relationship between the Honor Farm program and the Safe Parking program? Are there any issues?
F10:
The limited number of EAP visits for staff is likely not sufficient for supporting deputies with the trauma fatigue associated with their duties.
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R10:
Have there been any fentanyl incidents in the jail?
F11:
The facility has a supply of Narcan for use if needed by Coroner staff, but onsite Narcan had an expired date.
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R11:
What is your Narcan protocol and who carries it?
F12:
The transition between the former full-time pathologist to the current provider caused some backlog in cases. SAN LUIS OBISPO COUNTY PROPERTY ROOM
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R12:
What is the protocol for inmates who come in on prescription medication(s)?
F14:
There remains a need for additional storage space and climate control. COMMENDATION[S] In October 2022, the SLO Jail received accreditation for its health care services from the National Commission on Correctional Healthcare.
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R14:
Who administers these medications? QUESTIONS SUBMITTED TO SLO COUNTY JUVENILE HALL LEADERSHIP IN ADVANCE OF SITE VISIT:
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No vinculadas a hallazgos específicos.
R13:
Do they continue to receive these medications while in jail?
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Hallazgos & Recomendaciones
11 hallazgos
F1:
The combination of drought conditions and increased agricultural lands in production has resulted in an unsustainable decline in the Paso Basin.
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R1:
The GSAs need to expedite their plans to expand the monitoring network for use in the 2025 GSP update.
F2:
Since 1998 there has been over 700,000 AF reduction of groundwater storage resulting in dry wells for many rural residential properties and jeopardizing long-term agricultural viability.
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R2:
The GSAs need to employ the most accurate satellite data for determining groundwater utilization or adopt regulations which mandate reporting of groundwater extraction for agricultural production wells within the Paso Basin by the 2025 GSP update.
F3:
The current number and location of groundwater monitoring well data collected by the PBCC is insufficient for decision making.
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R3:
Implementation of the proposed MILR Program, to establish voluntary land fallowing, needs to be initiated by the 2025 GSP update. If voluntary measures are ineffective, the PBCC will need to implement a mandatory program.
F4:
The PBCC currently does not require or have full access to the annual volume of groundwater pumping by all agricultural users to determine the extent of the demand on the basin.
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R4:
The GSAs must establish and implement the necessary governance structure to build public trust and execute procedures up to and including formal regulations to define equitable groundwater extractions and enforcement mechanisms.
F5:
The GSP initiatives for feasible supplemental water options and conservation measures are insufficient to balance the basin. Basin recovery depends upon reduction in active agricultural production pumping.
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R5:
GSAs should intensify outreach to solicit public input and educate residents and property owners, particularly those whose wells have run dry. Outreach should include the development of a collective single website for the PBCC.
F6:
The failure of the PBCC to apply equitable pumping restrictions has resulted in continued decline of the Paso Basin.
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R6:
In consideration of equitable use of groundwater, the PBCC needs to develop a plan to set aside funds and an administrative mechanism to ensure that rural residential users have access to water.
F7:
Public information and outreach on Paso Basin status is inadequate.
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R7:
By Fiscal Year 2024/25, the County GSA should impose user fees to eliminate the need for County General Fund contributions and to implement the necessary programs for basin sustainability.
F8:
Fees that would make the GSP self-sustaining are not uniformly applied across the GSAs. Unincorporated areas governed by the County are not collecting fees.
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R8:
Once the GSAs have enacted management measures which ensure the basin is stabilized, the County Board of Supervisors should revise their existing planting ordinance to allow for equitable agricultural use of properties.
F9:
Rural residential wells remain at risk. Many rural residential users lack the resources and means to correct the situation.
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R9:
For the 2025 GSP annual update, the Cooperative Committee should update the GSP timeline to show a realistic and deliverable set of management actions.
F10:
There remains an inequity between rural properties in using groundwater for agricultural production under the 2013 County Planting Ordinance.
F11:
Management efforts have not advanced sufficiently to begin regulation of basin activities.
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Hallazgos & Recomendaciones
5 hallazgos
F1:
SLO County has failed to create and maintain a safe, orderly, effective, and efficient means for ensuring the persons experiencing mental health issues receive the care they need, when the need it. The average and sometimes extended time periods Held persons spend in local emergency rooms prior to placement in an appropriate treatment facility is unacceptable as demonstrated by records from multiple emergency room encounters. The respondent disagrees partially with this finding. The County fully recognizes the ongoing and statewide crisis in lack of appropriate resources for individuals experiencing psychiatric emergencies. This crisis is well documented; the attached report from the Rand Corporation provides detail. This crisis is not unique to SLO County. In fact, the length of stay for patients in local emergency departments is roughly on average with that of other hospitals in other parts of the State, even in counties where there are multiple privately operated psychiatric hospitals. Two areas of particular concern have been the lack of psychiatric hospitals willing or able to accept individuals who test positive for Covid-19, and the lack of pediatric psychiatric facilities. Individuals who test positive for COVID-19 have remained in emergency departments statewide for longer periods of time than desired. The second area is the lack of pediatric psychiatric facilities, so youth have at times spent multiple days in emergency departments awaiting an appropriate placement. Neither of these situations are beneficial to the patients or their families, but are an unfortunate result of the lack of facilities in SLO County and statewide to meet the specialized needs of these patients. Addressing this crisis effectively will require the full participation and engagement of multiple local entities, each with a distinct legal responsibility and area for potential impact. The County Health Agency has the responsibility to pay for inpatient treatment for County Medi-Cal beneficiaries. Beyond this legal responsibility, the County has also unilaterally increased services to provide care for individuals in psychiatric crisis. Hospitals with dedicated emergency departments have the responsibility to screen, stabilize, and transfer all individuals who present to their campuses. Responding to this crisis is a shared responsibility and the County is ready to continue working together toward a solution.
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R1:
SLO County should commit to creating a single, integrated, and unified mental health services center that houses the PHF, the CSU, the MHET, outpatient coordination, juvenile mental health services, and that includes a medical health triage and screening facility where all Held persons, regardless of age, categorization, or insurance status, can be medically cleared prior to placement in an appropriate section of the mental health facility. This recommendation has not yet been implemented, but may be implemented in the future. The County Behavioral Health Department fully embraces the concept of a “one stop shop” and a full continuum of care for individuals with psychiatric or addiction care needs. The idea of a multi-service site has been planned as part of the anticipated Health Campus remodel, originally planned for 2024-25. This plan had to be set aside during the Covid-19 pandemic response. Once the Health Campus project is re-initiated, plans to develop a multiple service site will continue. The ability to fund such services to be agnostic of payor (that is, to be available for those with private insurance as well as those with Medi-Cal coverage) would need to be fully evaluated over time. The Mental Health Plan, which is the role of the County Behavioral Health system under contract with the Department of Health Care Services, in coordination with CenCal Health, could develop a unified service for individuals who are SLO County Medi-Cal beneficiaries. Integration, or at a minimum, co- location, of physical and behavioral health care is a goal of the California AIM (Advancing and Innovating Medi-Cal) project to improve Medi-Cal services across the State. Certain restrictions due to current State licensing and regulations limit the ability to have multiple services under one roof or provided by a single agency. One model of co-location, currently existing in Orange County, was only able to be created by having different providers for crisis stabilization, PHF, sobering, physical health screening, etc. At this time, the effectiveness of this project is still being evaluated; however, it provides one model to consider. The County hopes that State and Federal regulations may allow for more flexible implementation of projects such as this. R.2: SLO County should relieve the four private hospitals in our County of the responsibility for warehousing Held persons. The respondent notes that this item requires further analysis. The Health Agency has recently convened a new executive steering committee to develop collaborative approaches to address the impact of psychiatric crisis on the 4 local emergency departments. The Health Agency Interim Director will report on the progress of this committee in 6 months. The County fully recognizes the ongoing and statewide crisis in lack of appropriate resources for individuals experiencing psychiatric emergencies. This crisis is well documented; the attached report from the Rand Corporation provides detail. This crisis is not unique to SLO County. In fact, the length of stay for patients in local emergency departments is roughly on average with that of other hospitals in other parts of the State, even in counties where there are multiple privately operated psychiatric hospitals. The Health Agency complies with Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex or any other protected class County of San Luis Obispo Health Agency 2180 Johnson Avenue | San Luis Obispo, CA 93401 | (P) 805-781-4719 | (F) 805-781-1273 6 of 52 slobehavioralhealth.org Two areas of concern have been the lack of psychiatric hospitals willing or able to accept individuals who test positive for Covid-19. These individuals have ended up remaining in emergency departments statewide for longer period of times than desired. The second area is the lack of pediatric psychiatric facilities, so youth have at times spent multiple days in emergency departments awaiting an appropriate placement. Neither of these situations are beneficial to the patients or their families, but are an unfortunate result of the lack of facilities either in SLO County or statewide to meet the specialized needs of these patients. Addressing this crisis effectively will require the full participation and engagement of multiple local entities, each with a distinct legal responsibility and area for potential impact. The County Health Agency has the responsibility to pay for inpatient treatment for County Medi-Cal beneficiaries. Beyond this legal responsibility, the County has also unilaterally increased services to provide care for individuals in psychiatric crisis. Hospitals with dedicated emergency departments have the responsibility to screen, stabilize, and transfer all individuals who present to their campuses. Responding to this crisis is a shared responsibility and the County is ready to continue working together toward a solution. R3. SLO County should seek the financial resources needed to hire and retain outpatient mental health services professional staff in sufficient number to allow for reasonable and customary management ratios. This recommendation requires further analysis. The Health Agency, in coordination with the County Human Resources Department, will continue to identify and pursue opportunities to recruit and retain qualified staff. This analysis will be followed up within 6 months. R4. SLO County should seek the financial resources needed to hire and retain mental health services professional staff in sufficient number to meet the needs of Held juveniles within our county. This recommendation requires further analysis. The responsibility of the County is to serve individuals who are Medi-Cal beneficiaries, or who are indigent. The responsibility of the Mental Health Plan, the contracted services between the County and the State Department of Health Care Services, is to pay for medically necessary inpatient care for all SLO County Medi-Cal beneficiaries. SLO County will continue to collaborate with other providers, both locally and statewide, to develop additional services for minors, including a continuum of crisis services. The Interim Health Agency Director has recently convened an Executive Steering Committee to seek collaborative partnerships to further develop resources for all community members requiring psychiatric care. R.5 The SLO County Sheriff’s Office, SLO County Behavioral Health Services, and the SLO County Board of Supervisors should jointly devise and implement a plan to ensure that properly trained and certified correctional officers are assigned in sufficient number to provide for the safety and security of all staff and held persons when such persons are in the County’s care and custody no matter which facility is responsible for the patient. This recommendation item requires further analysis. 2 7 of 52 At this time, the Health Agency contracts with a local security company that has been able to fully staff 2 FTEs of security 24/7 for the PHF and the Health Campus, as directed by the County CAO. Further discussion related to the Sheriff’s Office will be managed by the Interim Health Agency Director. 3 8 of 52 Evaluation Report CORPORATION RYAN K. MCBAIN, JONATHAN H. CANTOR, NICOLE K. EBERHART, SHREYA S. HUILGOL, INGRID ESTRADA-DARLEY Adult Psychiatric Bed Capacity, Need, and Shortage Estimates in California—2021 Summary Psychiatric beds are essential infrastructure for meeting the needs of individuals with mental health conditions. However, not all psychiatric beds are alike: They represent infrastructure within differ- ent types of facilities, ranging from acute psychiatric hospitals to community residential facilities. These facilities, in turn, serve clients with different needs: some who have high-acuity, short-term needs and others who have chronic, longer-term needs and KEY FINDINGS may return multiple times for care. ■ California faces an estimated 1.7-percent growth in its psychiatric bed California, like many parts need from 2021 to 2026. of the United States, is confront- ■ California faces shortages of psychiatric beds at all three major levels ing a shortage of psychiatric beds. of adult inpatient and residential care. This shortage manifests in high ■ Significant regional differences in the estimated shortfall of beds were bed occupancy rates and long wait noted at each level of care. lists for placements. However, determining the primary drivers ■ Growth in the need for psychiatric beds is projected to be largest in the Northern and Southern San Joaquin Valley. of this shortage—accounting for regional variation in psychiatric ■ Hard-to-place populations contribute disproportionately to bottle- bed capacity at different levels of necks in the existing system. care—is a challenging problem to ■ A majority of psychiatric facilities at all levels of care reported an tackle. Nevertheless, California inability to place individuals with comorbid dementia or traumatic brain is committed to expanding the injury, nonambulatory individuals, those requiring oxygen, and those mental health infrastructure, who tested positive for COVID-19. Individuals involved in the criminal justice system were reportedly difficult to place in community residen- including psychiatric bed capacity. tial settings. How, where, and to what extent 9 of 52 these investments should be made remains an open To estimate psychiatric bed need, we used several question. approaches for the purpose of triangulation. First, In this report, we estimated psychiatric bed we contacted psychiatric facilities throughout the capacity, need, and shortages for adults at each of state and spoke with administrative leaders at these three levels of care throughout California. These facilities to quantify bed occupancy rates, wait list three levels of care are acute, subacute, and commu- volume, average length of stay, and the number of nity residential services: individuals whom they would transfer to a higher or lower level of care if able to do so. Using the informa- • Acute care is directed toward those with the tion gathered, we were able to compute the number of highest acuity needs, is typically shorter term beds required—at each level of care in each region of (days to weeks), and is intended to stabilize the state—to reduce occupancy rates to 85 percent (a patients. standard ceiling) and accommodate wait list volume • Subacute care is directed toward those with and requested transfers. We calculated these estimates moderate- to high-acuity needs for a longer excluding state hospitals and, separately, including duration (multiple months). state hospitals, prioritizing the former approach. Our • Community residential services are intended rationale for this is that state hospital beds are gener- to address lower acuity and longer-term ally not considered part of the continuum of care at care (often multiple years) that is focused on a local level in terms of decisionmaking purposes. patient recovery. Second, we moderated this bottom-up estimate We computed these estimates with and without the by incorporating epidemiological information on inclusion of state hospitals, which often provide care regional variation in serious psychological distress for unique subpopulations who may be hard to place in (SPD) among adults, which serves as an indicator of other settings, including those with high acuity, long- psychiatric bed need. Third, as a top-down approach, term needs. Additionally, we projected growth in the we convened a Technical Expert Panel to deliberate need for psychiatric beds in the period of 2021 to 2026. and arrive at normative estimates of psychiatric bed need available from the research literature. Approach Lastly, we projected the need for psychiatric beds in the period from 2021 to 2026. To accomplish this, Our population of interest comprised adults (18 years we first quantified the prevalence of SPD according or older) throughout California. The corresponding to demographic categories (i.e., sex, race/ethnicity, sampling frame contained all psychiatric facilities and age group) among adults in California, using the with psychiatric beds serving adults throughout Cali- California Health Information Survey. From this, fornia’s 58 counties. Because individuals might access we were able to estimate the regional prevalence of psychiatric facilities (and beds) outside their county SPD in 2026, based on evolving demographic trends. of residence, we aggregated estimates at a regional Next, we cross-walked the estimated prevalence of level using the U.S. Census Bureau classification. SPD to the likelihood of requiring inpatient psychi- To estimate psychiatric bed capacity, we synthe- atric services, based on the proportional need for sized an array of data sets from state agencies that inpatient psychiatric services among individuals with are responsible for licensure of psychiatric beds. To versus without SPD, according to the National Survey supplement this information, we employed a strati- on Drug Use and Health (NSDUH). fied randomized sampling approach to administer a survey to collect data on the number of beds at facili- ties and the number of beds occupied. We provided Key Findings estimates to county points of contact at behavioral Psychiatric bed capacity. We estimated that Cali- health departments to review and revise them with fornia has a total of 5,975 beds at the acute level (19.5 an eye to improving accuracy. per 100,000 adults) and 4,724 at the subacute level (15.4 per 100,000 adults)—excluding state hospital 2 10 of 52 beds. If state hospital beds are included, these fig- ures increase to 7,679 (25.1 per 100,000 adults) and 9,168 beds (29.9 per 100,000 adults), respectively. We also observed large regional variation. For example, Growth in the need excluding state hospitals, acute bed capacity ranged for psychiatric beds is from 9.1 beds per 100,000 adults in the Northern San Joaquin Valley to 27.9 beds per 100,000 adults in the projected to be largest Superior region. For subacute bed capacity, regional estimates ranged from 7.4 to 31.8 beds per 100,000 in the Northern and adults. At the community residential level, we esti- mated that California has a total of 3,872 beds (12.7 Southern San Joaquin per 100,000 adults). Psychiatric bed need. Using observed occupancy Valley. rates, wait list volumes, and requested transfers, we estimated that California requires 50.5 inpatient psychiatric beds per 100,000 adults: 26.0 per 100,000 Psychiatric bed shortages. Synthesizing figures for at the acute level and 24.6 per 100,000 at the subacute bed capacity and bed need, we estimated that the state level, or 7,945 and 7,518 beds, respectively. At the has a shortfall of approximately 1,971 beds at the acute community residential level, we estimated a need of level (6.4 additional beds required per 100,000 adults) 22.3 beds per 100,000 adults. and a shortage of 2,796 beds at the subacute level (9.1 Estimated prevalence of SPD in California ranged additional beds required per 100,000 adults)—or 4,767 from 7.9 percent in the San Francisco Bay Area to subacute and acute beds combined, excluding state hos- 9.3 percent in the Southern San Joaquin Valley. When pital beds. If state hospitals were included in this esti- we incorporated this epidemiological information mate, the shortage of acute inpatient beds would shrink into our psychiatric bed need estimates, this intro- to 267, and there would be no observable shortage in duced regional variation in psychiatric bed need that beds at the subacute level. Separately, we estimated a ranged from 45.5 to 55.5 inpatient psychiatric beds per shortage of 2,963 community residential beds. 100,000 adults. Lastly, we collected secondary esti- The top-down estimates of psychiatric bed mates of psychiatric bed need from the academic lit- need—as drawn from the literature and our Techni- erature and our Technical Expert Panel. Using median cal Expert Panel—also indicated a bed shortage: 8.9 values, we generated a separate, top-down estimate beds per 100,000 adults at the acute level and 10.6 of psychiatric bed need: 27.5 beds per 100,000 adults beds per 100,000 adults at the subacute level. There- at the acute level and 25 per 100,000 at the subacute fore, our bottom-up and top-down estimates were level. We were unable to provide a comparable top- closely aligned. The remaining discrepancy likely down estimate of need for community residential beds pertains to differences in the configuration of health because of the significant heterogeneity within this systems throughout the United States and interna- classification and the paucity of academic literature. tionally, including availability of outpatient services We estimate that the magnitude of need for psychi- and alternatives to hospitalization, that drive need. atric beds is expected to grow modestly over the next When regional prevalence estimates for SPD were five years (2021 to 2026): by 1.7 percent. This is primar- incorporated, the gap in beds required reduced mod- ily due to shifting demographic trends, including adult estly: by 4.5 percent. We also documented significant population growth and increasing racial/ethnic diver- regional differences in the estimated shortfall of beds sity, because epidemiological data indicate that His- on the basis of the wide regional variation in psychiat- panic and Black adults experience SPD at higher rates ric bed capacity. For example, two regions of the state than do White adults. Growth in the need for psychi- appear to have sufficient acute inpatient psychiatric atric beds is projected to be largest in the Northern and bed capacity, whereas the remaining eight regions Southern San Joaquin Valley—by about 4.0 percent. 11 of 52 3 have a shortfall. At the subacute level, all regions such regions as the Central Coast, Inland (apart from the Northern San Joaquin Valley) appear Empire, and Southern San Joaquin Valley. to have a shortfall. However, the magnitude of this 2. Consider focusing on building or remodel- shortfall ranges from 5.1 additional beds required per ing infrastructure for the most hard-to-place 100,000 adults in the North Coast region of the state populations. Specific subpopulations appear to 17.2 additional beds required per 100,000 adults in to contribute disproportionately to bottle- the Southern San Joaquin Valley. necks in the current system, including an Lastly, we inquired about hard-to-place popula- inability to transfer patients with criminal tions. Here, we found that a majority of psychiatric justice involvement from the subacute level of facilities at all levels of care reported an inability to care to community residential settings. Given place individuals with comorbid dementia or trau- this, the state might need to consider alterna- matic brain injury, nonambulatory individuals, those tive arrangements for placing such popula- requiring oxygen, and those who tested positive for the tions, such as community-based and outpa- coronavirus disease 2019 (COVID-19). A majority of tient competency restoration programs. Here, respondents from community residential facilities also California could learn from other mental reported an inability to place individuals involved in health systems across the United States and the criminal justice system—particularly those with internationally. arson or sex offense convictions. 3. Set aside state funds for a system that reviews licensure data and periodically collects psychiatric facility–level information. Our Recommendations analysis and conclusions contain numerous Using these findings, we came up with three caveats, in large part because of poor data recommendations: quality. We wish to be transparent about this fact, with the hope that this serves as an impe- 1. Prioritize psychiatric bed infrastructure in tus for the state to consider investing in an the areas with the greatest need. In terms of adequate data review and monitoring system. an absolute shortfall of beds, the shortfall If the state were to allocate funds to routinely was greatest in terms of subacute beds, driven monitor and purge licensure data, policymak- partly by four regions (Los Angeles County, ers would be in a much stronger position to San Francisco Bay Area, Inland Empire, Supe- know what the existing capacity is at each rior region) that represented a shortfall of level of care—particularly at the community more than 2,000 beds—more than a quarter residential level. Likewise, the state should of all additional beds needed throughout the consider establishing a mechanism by which state. If policymakers examine the psychiatric psychiatric facilities report periodically on bed bed shortfall as a proportion of regional adult occupancy rates, wait list volume, number of population, this might lend greater weight to requested transfers to higher and lower levels regions with smaller or more rural popula- of care, and psychiatric patient boarding in tions: For example, the shortfall of subacute emergency departments. The state should also beds is 5.2 beds per 100,000 adults in Los consider collecting sociodemographic and Angeles County compared with 17.2 per clinical information on patients who use psy- 100,000 adults in the Southern San Joaquin chiatric beds. This would allow California to Valley. We also observed significant need for have a remarkably precise and sensitive system acute beds in such regions as the Northern for tracking the impact of investments that and Southern San Joaquin Valley and Central seek to address psychiatric bed shortages. Coast, while the shortfall at the community residential level was particularly notable in 4 12 of 52 Introduction Role of Psychiatric Beds Today, hundreds of Psychiatric beds are essential infrastructure for Californians in need of meeting the needs of individuals with serious mental health conditions.1 These beds serve several psychiatric beds are functions—including enabling safe, stable, and sup- held in hospital EDs or portive environments for individuals in acute mental health crises and for those with significant impair- county jails awaiting ment who require ongoing medical monitoring.2 Not all psychiatric beds are alike, because they openings in inpatient represent infrastructure within different types of facilities. For example, psychiatric beds in acute inpa- care settings. tient hospitals serve those in need of secure, 24-hour care and often include crisis stabilization units. The average length of stay in such states as California is resolution and triage services, acute inpatient ser- one to two weeks.3 By contrast, psychiatric beds in vices, subacute services, state hospitals, and com- such subacute facilities as mental health rehabilita- munity residential services. Clinical guidelines, such tion centers (MHRCs) or special treatment programs as the Level of Care Utilization System, enforced by at skilled nursing facilities (SNFs)—which provide the state of California through Senate Bill (SB) 855 longer-term recovery-oriented services, such as inde- (2020),8 provide a useful compass for matching an pendent life skills training—may remain occupied by individual’s needs with an appropriate level of care. the same individuals for many months.4 Ultimately, psychiatric beds represent an impor- tant component in a continuum of behavioral health Psychiatric Bed Shortfall care that includes integrated community services Psychiatric bed capacity is severely strained in Cali- ranging from prevention and screening to emergency fornia, as it is in much of the United States.9 The crisis response. Depending on the arrangement of present situation may be viewed, in part, as the long services, the need for psychiatric beds may look dif- tail of an effort to deinstitutionalize psychiatric ser- ferent. For example, the CrisisNow model of emer- vices throughout the United States during the latter gency care instituted in Arizona has significantly half of the 20th century: from a peak of 337 psy- reduced the state’s volume of psychiatric emergency chiatric beds per 100,000 individuals in the United department (ED) boarding.5 Assertive Community States in 1955 to a low of around 12 beds per 100,000 Treatment and similar models, such as Full Service in 2016.10 This transition to community-based Partnership programs, may also be key contribu- services—although well-intentioned—has resulted in tors. These models employ transdisciplinary teams a paucity of infrastructure to serve the needs of indi- to provide comprehensive services to patients who viduals who would otherwise benefit from a stable have needs that have not been adequately met by and supervised residence, particularly those with traditional approaches.6 According to the Substance serious mental illness (SMI).11 Abuse and Mental Health Services’ Behavioral Today, hundreds of Californians in need of psy- Health Treatment Services Locator, there are 133 chiatric beds are held in hospital EDs or county jails mental health treatment facilities in California that awaiting openings in inpatient care settings.12 In offer these services, though these services may be addition, a sizable percentage of chronically home- underreported.7 less individuals have an SMI.13 As county jail and With regard to psychiatric beds specifically, homeless populations continue to swell, these rising California embeds psychiatric beds within crisis numbers have created an increasing urgency to take 13 of 52 5 Estimating the need for psychiatric beds is a thorny undertaking. There are no standardized Given the diversity and approaches or best practices, and health systems geographic distribution are constructed differently at the regional and state levels. However, prior literature outlines at least of both adults and four methods for calculating the number of psy- chiatric beds that are needed to address population psychiatric facilities needs. These methods include (1) expert consensus, (2)a normative approach, (3) a population health in California, needs approach, and (4) an observed outcomes approach.16 We briefly survey these approaches, including their throughout the state are strengths and limitations. Expert consensus. Calculating psychiatric bed heterogeneous. need by expert consensus relies on open discussion among content and methods experts—who opera- tionally define a set of relevant principles, deliberate action. For example, in early 2021, an estimated 1,600 evidence, and then achieve mutual agreement on adults in need of psychiatric beds were residing in standards. A key example of this approach is a 2008 county jails because they had been deemed incompe- report by the Treatment Advocacy Center (TAC),17 tent to stand trial and were unable to be placed by the which interviewed 15 experts to deliberate and arrive Department of State Hospitals (DSH).14 Legislators, at a suggested benchmark for measuring psychiatric meanwhile, have called for an overhaul of state psy- bed need: 40 to 60 beds per 100,000 in population.18 chiatric services—particularly against the backdrop of Although expert consensus is a helpful method the COVID-19 pandemic.15 for arriving at an estimate of psychiatric bed need, this approach has limitations. The report by TAC did Measuring Need for Psychiatric Beds not outline the precise deliberations that led experts to arrive at their conclusion, making it challenging Estimating the need for psychiatric beds in Califor- to scrutinize the estimate or replicate the process. nia is essential for at least three reasons. First, when Furthermore, without a set of operational definitions estimates on the need for psychiatric beds are paired for such terms as psychiatric bed, it remains unclear with estimates on the existing bed capacity, evalu- whether a specific benchmark would translate in other ators can determine the magnitude of the shortfall settings or how one would go about allocating 40 to 60 in beds throughout the state, allowing policymak- beds per 100,000 in population across different levels ers to discuss investments accordingly. Second, the of care. The number and types of beds required are estimation process can serve a diagnostic function: liable to depend on local context and resources. Given the diversity and geographic distribution Normative approach. The normative approach of both adults and psychiatric facilities in Califor- to calculating psychiatric bed need is predicated nia, needs throughout the state are heterogeneous. on an assumption that jurisdictions (or countries) Lastly, if the need for psychiatric beds is estimated with similar health systems and demographic char- at multiple intervals, these estimates can provide an acteristics are likely to require a similar number ongoing feedback mechanism for fine-tuning invest- of psychiatric beds. In this scenario, a jurisdiction ments. Because needs are dynamic, investments in with more-robust psychiatric facility infrastruc- infrastructure at any given time may only partially ture has the potential to serve as a comparator for address problems. This factor should create an impe- others. For example, the Organisation for Economic tus to determine how effective initial investments Co-operation and Development has employed this were and to plan for new investments for new needs approach to compare mental health infrastructure have arisen. across its 38 member countries, providing annual- 6 14 of 52 ized estimates of psychiatric beds per 100,000 in for example, the Department of Health used popu- population—with a low of 3 beds per 100,000 in lation and demographic estimates to calculate the population in Mexico to 259 per 100,000 in popula- total psychiatric bed need as 30 beds per 100,000 in tion in Japan (the United States ranks seventh from population.23 Other states (Mississippi, Oklahoma, the bottom at 25 per 100,000).19 The World Health Missouri) have performed similar calculations, using Organization has followed a similar model with its a fixed population ratio to arrive at estimates of need Mental Health Atlas project.20 Coupled with other ranging from 20 to 117 psychiatric beds per 100,000 indicators (e.g., hospital readmission rates), compara- in population.24 This wide range in values is indica- tive analyses can be used to determine whether and tive of disconcerting variation in the parameters used to what extent more-robust infrastructure translates to come up with these estimates. to improved population health outcomes. Calculating the number of psychiatric beds The main challenge with the normative approach needed from this population health approach assumes is that there are large differences in the number of certain targets for specific mental health conditions, psychiatric beds per capita even within countries which may be more or less accurate. For example, that have similar health and economic systems. Fur- there is a paucity of epidemiological data on the likeli- thermore, understanding the difference in reported hood of an individual requiring specific services based numbers of psychiatric beds is difficult because there on mental health diagnosis and illness severity, and on is no standard definition for psychiatric bed. Coun- the optimal duration and intensity of service provi- tries like Italy do not consider residential treatment sion. Relying on limited information risks generating facilities to constitute inpatient care, producing a inaccurate predictions for the number of psychiatric much lower estimate per 100,000 in population com- beds needed and may underpin the wide variation pared with countries that include residential treat- observed in estimates across states—which are often ment facilities.21 Additionally, what works for some using differing sets of assumptions. countries and systems in terms of psychiatric bed Observed outcomes approach. The observed needs and mental health services may not work in outcomes approach is based on the observation that others. Individual countries may first need to define heterogeneous psychiatric bed capacity across coun- their core mental health services and set data-driven ties and states is liable to have observable effects on targets to meet those needs. One recent study found health systems and populations.25 By looking at the that, out of 32 mental health plans developed across relationship between psychiatric bed capacity and key five countries, only four plans included specific tar- performance indicators—such as wait times, occu- gets for their core services—including psychiatric pancy rates, length of stay, emergency room board- bed needs.22 These sorts of comparative metrics are ing, and population health outcomes—researchers also generally lacking within the United States across have the potential to calculate minimum and optimal regions and counties. psychiatric bed capacity requirements from an induc- Population health approach. A population tive perspective.26 Along these lines, in 2020, the San health approach identifies the prevalence of mental Francisco Department of Public Health conducted a health conditions within a geographic area and simulation to assess psychiatric bed need, which ana- then applies a set of standards to meet population lyzed more than 25,000 mental health–related admis- health needs in accordance with these prevalence sions and accounted for variable bed occupancy rates estimates—including quantifying psychiatric services across different levels of care.27 The authors of the and corresponding infrastructure, such as psychi- report concluded that observed bed occupancy rates atric beds. One advantage of this approach is that greater than 85 percent have the potential to contrib- prevalence estimates for particular mental health ute to bottlenecks and flow issues over the long run conditions (and, by extension, needs that derive and suggested an additional 97 beds across four types from these conditions) are sensitive to the underly- of facilities to achieve zero wait time. ing demographic characteristics of the region—such The observed outcomes approach has also been as age, sex, and income distributions. In Tennessee, criticized.28 Specifically, researchers have argued that 15 of 52 7 key performance indicators tend to concentrate on bill’s provisions allow local governments to purchase process measures pertaining to hospital administra- psychiatric facilities to prevent closures and require that tion, which may have little correspondence to patient facility owners give residents greater advanced notice outcomes. Furthermore, hospital functioning may be prior to closure. Several complementary bills signed into dependent on a wide array of factors, such as employ- law earlier this year, including AB 27, AB 362, AB 816, ment rates or social determinants of health within AB 977, AB 1220, AB 1443, and SB 400, represent part the local community. Therefore, these extraneous of a $22 billion investment to address homelessness and factors may function as confounders during analysis the need for behavioral health services. The investments unless they are incorporated as covariates. include $3 billion dedicated to housing for those with Ultimately, as noted earlier in this report, there are acute behavioral and physical health issues—with an no consensus best practices for determining psychiat- expectation of creating approximately 22,000 new beds ric bed needs. The most robust approach may therefore and treatment slots.33 be to inspect the problem from multiple vantage points Additional Assembly legislation, AB 2265, has and methodologies to converge on a triangulated set of focused on increasing access to treatment by allow- estimates for psychiatric bed needs. This includes—to ing California counties to use mental health services the extent possible—pressure testing the approaches funds to address not only mental health conditions outlined above by performing sensitivity analyses. but also substance use disorders, with the goals of We have therefore elected to assume this triangulated enhancing care coordination and creating an inte- approach in our analysis, as further described in the grated behavioral health care system.34 In the context “Methods” section. of psychiatric bed infrastructure, this legislation is particularly relevant for populations in need of longer-term rehabilitative services who are coping California’s Investment in Infrastructure with comorbid substance use and mental health con- California has stated a commitment to expand mental ditions. It was signed into law on September 24, 2020. health infrastructure, including psychiatric bed capacity.29 In early 2020, the California Mental Health Purpose of This Report Services Authority (CalMHSA) announced the forma- tion of a Behavioral Health Task Force, appointed to In this report, we provide an estimate of current advise Governor Newsom on efforts to reform and psychiatric bed capacity throughout the ten census advance behavioral health services throughout the regions of California, according to three overarching state.30 Since the onset of the COVID-19 pandemic levels of care: acute inpatient care, subacute inpa- in 2020, Newsom has signed numerous bills into law tient care, and community residential treatment. We that aim to increase Californians’ access to mental then compare the measure of current psychiatric health services. As noted earlier in this report, these bed capacity with estimates of psychiatric bed need. bills include SB 855, which requires commercial health Lastly, we project bed capacity needs over the next insurance plans outside Medi-Cal to provide medically five years, based on evolving demographic trends necessary treatments for all mental health conditions throughout the state. and substance use disorders.31 The bill also requires We note that the primary bed estimates provided that health plans provide services that comply with in this report do not include state hospitals, although level of care determinations as outlined in the Level of we provide secondary estimates for which state hos- Care Utilization System, American Society of Addic- pitals are included. This decision was based on three tion Medicine criteria, and other clinical guidelines for factors. First, more than 90 percent of psychiatric pediatric populations. beds at state hospitals are occupied by individuals Separately, Assembly Bill (AB) 2377—which was involved in the criminal justice system.35 Thus, state also ratified in 2020—sought to mitigate the impact of hospitals serve a set of clients with unique constraints adult residential facility closures and help residents at that do not apply to local behavioral health con- risk of homelessness in California.32 Specifically, the tinuums that we examine in detail throughout this 8 16 of 52 report. In addition, the forensic population census ization of these facilities and portfolio of services may has continued an upward trend that portends a con- vary. Given this factor, we assigned facilities to three tinued reduction in beds available for non-forensic levels of care—matching closely to a conceptual model individuals. Second, the exclusion of state hospitals established by the County Behavioral Health Directors has the secondary benefit of modeling need for psy- Association of California.37 The levels were defined by chiatric beds if state hospitals were transitioned to two axes: first, the acuity of need being attended to, local, community-based alternatives. Third, unlike ranging from emergent crises to nonemergent, ongo- other types of facilities, state hospitals are not broadly ing supports; second, typical length of stay, ranging distributed throughout the state. This distribution from short term (days to weeks) to long term (months results in computational challenges for determining to years). With the exception of community residen- psychiatric bed shortages in regions that contain state tial facilities, length of stay is usually time-delimited hospitals, especially because not all patients within according to the particular type of facility. state hospitals are residents from the region in which Operationally, we defined the three levels of care that state hospital is located. We discuss further as follows: details in the “Methods” section. 1. acute, representing highly structured, around- We supplement these quantitative analyses with the-clock medically monitored inpatient care input from our panel of technical experts. Using the for individuals at heightened risk of harm to combined results, we outline a series of recommenda- themselves or others, or those who are other- tions. These recommendations pertain to the expan- wise unable to care for themselves sion of psychiatric bed capacity to address existing 2. subacute, representing around-the-clock gaps, and they are situated in California’s context of inpatient care that includes specialized pro- ongoing legislative efforts to establish a holistic con- gramming in a controlled environment with a tinuum of behavioral health care services. significant degree of supervision but with less intensive medical monitoring and interven- tion than acute care Methods 3. residential, representing nonhospital pro- Population and Scope grams in which individuals live on the prem- ises of a facility and are provided with consis- Our population of interest comprised all adults (18 tent programming to promote interpersonal years or older) in California, across all 58 counties. and independent living skills, with staff pres- Because individuals may access psychiatric facili- ent 24 hours a day, seven days a week. ties (and beds) outside their county of residence, we Table 1 details the types of facilities contained aggregated estimates of population, capacity, and within each of these levels of care, based on facility need at a regional level using the U.S. Census Bureau licensure information. classification: Superior California, North Coast, San State hospitals represent a unique type of institu- Francisco Bay Area, Northern San Joaquin Valley, tion. In other settings, acute care is short term and Central Coast, Southern San Joaquin Valley, Inland focused on stabilizing patients, whereas residential Empire, Los Angeles County, Orange County, and San Diego-Imperial.36 Although our denominator for care is lower intensity and geared toward long-term medical and nonmedical supports.38 In this sense, the calculations in this report included all adults in the two axes described above (acuity and length of California—because all adults have the potential to stay) are aligned. The expectation is that patients may use inpatient psychiatric services—a disproportion- transition up and down the care continuum based ate number of those using psychiatric beds are adults on their needs at a given time point. However, state with SMIs, such as schizophrenia, bipolar disorder, hospitals are less dynamic and often provide care for and major depressive disorder. subcategories of patients with long-term, high acuity There are many types of psychiatric facilities in needs or based on medical necessity. For example, California. Depending on the county, the character- 17 of 52 9 TABLE 1 individuals who are incompetent to stand trial and are Levels of Care and Corresponding Adult awaiting transfer to an alternative care setting such Psychiatric Bed Infrastructure as a state hospital.42 Our rationale for this was that, although jail units are not suitable to serve as psychiat- Level of Care Types of Facilities Included ric beds (and therefore should not factor into capacity), Acute Acute psychiatric hospitals; psychiatric they are nevertheless housing individuals in need of (Level 3) health facilities; general acute care psychiatric beds. This was not possible for ED board- hospitals with psychiatric wards; acute beds at state hospitals ing. Although California generates an annual hospital utilization report, these reports do not contain ED Subacute General or specialized subacute facilities; (Level 2) MHRCs; SNFs with specialized treatment boarding rates among patients with mental health con- programs; institutions for mental disease; ditions.43 Likewise, there are no formal tallies of the subacute beds at state hospitals number of individuals with mental health conditions Residential Adult residential treatment facilities; who are receiving permanent supportive housing and (Level 1) enhanced or augmented board-and-care facilities; social rehabilitation facilities would otherwise benefit from alternative placement in a setting with psychiatric beds. NOTE: For a definition of psychiatric health facilities, see California De- partment of Health Care Services, 2021b. For a definition of institutions for mental disease, see California Department of Health Care Services, 2021c. Procedures state hospitals often house forensic patients (i.e., Focus group discussions. As a preliminary step, those involved with the criminal justice system), and, we conducted focus group discussions with county in California, many state hospital beds are reserved leaders at behavioral health departments throughout for such patients.39 This raises two questions: Should the state and members at CalMHSA and the County state hospitals be placed within the care continuum; Behavioral Health Directors Association. These and, if so, where? For the purposes of this report, we discussions focused on conceptual issues that these have remained agnostic to the first question, com- individuals were confronting with regard to sup- puting capacity and bed shortages with and without porting psychiatric bed needs. We focused on four inclusion of state hospitals. For the latter, we allo- topics: (1) perceived structural drivers of psychiatric cated acute state hospital beds to the acute level and bed shortages, (2) populations who were challenging subacute beds to the subacute level, both of which are to place in psychiatric facilities, (3) defining the care documented in licensure data sets.40 continuum, including which types of facilities cor- Specific populations and bed categories were respond to which levels of care, and (4) other areas deemed to be outside the scope of our analysis. of note that would be important for RAND research- Regarding populations, we excluded children and ado- ers to consider. We took detailed notes from each lescents, for whom there are subtle but important dif- discussion and deliberated the feedback provided to ferences in the care continuum and who were therefore us to develop our methodological approach, which is deemed to merit a separate analysis.41 Regarding bed detailed below. categories, we omitted beds corresponding to perma- Estimation of capacity. We downloaded the nent supportive housing, those in county jails, and most current licensure data available for each type those in EDs used for boarding patients with mental of psychiatric facility, using public data sets from health conditions. These categories are seldom quanti- the California Department of Public Health,44 Cali- fied as psychiatric beds because they are not exclu- fornia Department of State Hospitals,45 California sively reserved for populations with mental health Department of Health Care Services,46 and Cali- conditions, though it may be the case that individuals fornia Department of Social Services.47 These data with mental health conditions occupy one of these bed sets were then merged into a master file of facilities types. with psychiatric beds in California, and each facility For quantification of psychiatric bed need, we was geocoded at the address and county levels using incorporated the number of jail units occupied by ArcGIS Desktop 10.8.48 10 18 of 52 To validate facility licensure data, we executed need. In total, the Technical Expert Panel consisted two additional steps. First, we contacted behavioral of four participants whose names and titles can be health directors in all 58 counties in October 2021, found in Appendix B, alongside all major prompts providing them with an inventory of facilities within used during the panel’s discussion. their county and soliciting revisions. Where discrep- Estimation of need, Approach 3: population ancies arose, we prioritized the revisions detailed health assessment. Lastly, we drew from epide- by the county point of contact. Second, we reviewed miological data reported in the California Health 2,500 online entries for community residential Information Survey (CHIS) and NSDUH.50 Both the facilities to estimate the percentage of these facilities CHIS and NSDUH employ the Kessler 6, which is a within each county that provided services to indi- measure of psychological distress.51 A score of 13 or viduals with mental health conditions rather than greater indicates SPD, which is a marker of probable those with other types of disabilities or the elderly. SMI. This allowed us to rebalance regional need for For example, if we queried 60 community residential psychiatric beds based on (1) estimated regional prev- facilities in Orange County and found that 5 of 60 alence of SPD among adults, according to the CHIS, were psychiatric facilities with psychiatric beds, we and (2) expected utilization of psychiatric inpatient inferred that this percentage (5/60 = 8.3%) applied services among adults with versus without SPD in at the population level—that is, that 8.3 percent of the United States, based on NSDUH (which contains Orange County’s community residential facilities and estimates of self-reported receipt of inpatient mental beds were psychiatric facilities that contained psychi- health services in the past year).52 A substantial body atric beds. of literature has shown that SPD is a correlate of SMI Estimation of need, Approach 1: survey of and that those with SPD have a greater need for both psychiatric facilities. Using the observed outcomes outpatient and inpatient services.53 approach described earlier in this report, we drew a Projection of need. In addition to estimat- random sample of psychiatric facilities throughout ing current need for psychiatric beds, we projected California using Stata’s v.17 runiform command49 change in need over the next five years (2021 to and attempted to contact facility directors to inquire 2026). These estimates drew from expected trends about bed occupancy, average length of stay, wait in population growth and demographic shifts in the list volume, and the number of patients that facility age, sex, and racial/ethnic composition of the state directors recommended for transfer to a higher or according to U.S. Census Bureau information. The lower level of care. In the event that we were unable “Analysis” section provides a fuller description of the to reach an administrative leader at a particular facil- computations involved in this. ity, we made up to four additional attempted con- tacts per facility. For facilities that we were unable to Measures reach, we imputed estimates based on median values within the facility type and county, adjusting for total Psychiatric beds. We defined psychiatric beds as number of beds. Calls were made in October and beds within psychiatric facilities that have the pri- November 2021.
F2:
By relying on the four private hospital emergency rooms as the primary point of intake for persons experiencing mental health issues, Slo County has created a situation in which the quality and capacity of other emergency medical care within our county is at constant risk of degradation due to a variety of factors all relating to the requirement that those hospitals provide psychiatric services as primary care facilities for which they have little or no dedicated expertise or resources. The respondent disagrees with this finding. 1 2 of 52 While recognizing the ongoing local and statewide crisis in lack of appropriate resources for individuals experiencing psychiatric emergencies, it is not accurate to report that the County has created this situation. This situation has unfortunately resulted from complex factors that require a multi-faceted, multi-agency response in which all local entities, including both the County and local hospitals, fully meet their legal responsibilities for patient care. Currently, local hospitals are not fully complying with their federal and state legal responsibilities in this area. This fact, combined with the increase in psychiatric crisis, has contributed to a lack of potential resources, safety, and service to members of our community. Hospitals with dedicated emergency departments have the responsibility, under Federal law and State guidance, to medically screen, stabilize, and appropriately transfer all individuals presenting to the dedicated emergency department. While the Emergency Treatment and Labor Act (EMTALA) was enacted in 1986, further definitions have been included as of 1994 to ensure inclusion of psychiatric emergencies (42 CFR Section 489.24(b). The California State Department of Public Health issued an All- Facility Letter (CDPH All-Facility Letter 12-17) indicating that California hospitals “are required to comply with both state and federal requirements,” including the requirements related to psychiatric emergencies. California and San Luis Obispo County have seen an ever-growing number of individuals presenting to emergency departments with psychiatric emergencies, and the County has added services to provide care for these individuals and their families -- although federal and state law, and EMTALA Interpretive Guidelines, indicate the responsibility to do so lies with the hospital systems rather than with the County. The County now contracts with three transportation companies, soon to add a fourth, to assist with transportation to out-of-county facilities agnostic of payor source (in other words, for those who have private health insurance as well as for those enrolled in Medi-Cal, for whom CenCal Health has a legal responsibility to provide transportation for medically necessary services). CenCal Health has recently changed its policy and allows for direct payment to one of the transportation companies and has eliminated some of the pre-authorization barriers previously in existence. There is virtually no reimbursement to the County for the transportation services to individuals with private insurances, causing a use of public funds for services that should be covered by private insurance. The County, through Mental Health Services Act (MHSA) and grant funds, has increased both youth psychiatric crisis triage resources in the community, and has a dedicated 24 hour/day team to provide dispatch services. This team receives all requests from emergency departments to seek out of county (or local) inpatient placements, arranges for transportation, and assists with follow-up. Prior to the establishment of this team, all 4 hospitals relied fully on staff members of the PHF to provide transfer activities. This led to disruption in the treatment and supervision of the PHF as the supervisors were frequently called to “speed up” transfer activities. Current data shows that, while the statewide boarding of psychiatric patients in emergency departments averages over 30 hours, the Dispatch team of Sierra Mental Wellness Group (SWMG) in SLO County has an average of 24-30 hours length of stay, once notified by the hospitals of a need for evaluation. This program has done two important things: reduced disruption to treatment within the PHF, allowing PHF supervisors to focus on their own program, and managed to decrease or maintain length of stays in the 4 hospitals to at or below the statewide average. 3 of 52 In summary, the hospitals depend on the County to provide care for individuals in psychiatric distress, not the inverse as stated in this finding. The hospitals are responsible by law to provide screening, stabilization, and transfer for patients facing all emergency conditions, including psychiatric emergencies. The hospitals have contracts with placement and transportation companies for all medical diagnoses except for psychiatric conditions. The County has gone above and beyond its legal obligations to support patients in this area and will continue to encourage all local entities to fulfill their related responsibilities, for the benefit of patients and our community as a whole.
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R2:
SLO County should relieve the four private hospitals in our County of the responsibility for warehousing Held persons. The respondent notes that this item requires further analysis. The Health Agency has recently convened a new executive steering committee to develop collaborative approaches to address the impact of psychiatric crisis on the 4 local emergency departments. The Health Agency Interim Director will report on the progress of this committee in 6 months. The County fully recognizes the ongoing and statewide crisis in lack of appropriate resources for individuals experiencing psychiatric emergencies. This crisis is well documented; the attached report from the Rand Corporation provides detail. This crisis is not unique to SLO County. In fact, the length of stay for patients in local emergency departments is roughly on average with that of other hospitals in other parts of the State, even in counties where there are multiple privately operated psychiatric hospitals. The Health Agency complies with Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex or any other protected class County of San Luis Obispo Health Agency 2180 Johnson Avenue | San Luis Obispo, CA 93401 | (P) 805-781-4719 | (F) 805-781-1273 6 of 52 slobehavioralhealth.org Two areas of concern have been the lack of psychiatric hospitals willing or able to accept individuals who test positive for Covid-19. These individuals have ended up remaining in emergency departments statewide for longer period of times than desired. The second area is the lack of pediatric psychiatric facilities, so youth have at times spent multiple days in emergency departments awaiting an appropriate placement. Neither of these situations are beneficial to the patients or their families, but are an unfortunate result of the lack of facilities either in SLO County or statewide to meet the specialized needs of these patients. Addressing this crisis effectively will require the full participation and engagement of multiple local entities, each with a distinct legal responsibility and area for potential impact. The County Health Agency has the responsibility to pay for inpatient treatment for County Medi-Cal beneficiaries. Beyond this legal responsibility, the County has also unilaterally increased services to provide care for individuals in psychiatric crisis. Hospitals with dedicated emergency departments have the responsibility to screen, stabilize, and transfer all individuals who present to their campuses. Responding to this crisis is a shared responsibility and the County is ready to continue working together toward a solution. R3. SLO County should seek the financial resources needed to hire and retain outpatient mental health services professional staff in sufficient number to allow for reasonable and customary management ratios. This recommendation requires further analysis. The Health Agency, in coordination with the County Human Resources Department, will continue to identify and pursue opportunities to recruit and retain qualified staff. This analysis will be followed up within 6 months. R4. SLO County should seek the financial resources needed to hire and retain mental health services professional staff in sufficient number to meet the needs of Held juveniles within our county. This recommendation requires further analysis. The responsibility of the County is to serve individuals who are Medi-Cal beneficiaries, or who are indigent. The responsibility of the Mental Health Plan, the contracted services between the County and the State Department of Health Care Services, is to pay for medically necessary inpatient care for all SLO County Medi-Cal beneficiaries. SLO County will continue to collaborate with other providers, both locally and statewide, to develop additional services for minors, including a continuum of crisis services. The Interim Health Agency Director has recently convened an Executive Steering Committee to seek collaborative partnerships to further develop resources for all community members requiring psychiatric care.
F3:
SLO County does not provide adequate resources to ensure the safety and security of both County and contractor staff who work in mental health services facilities and hospitals based on documented incidents. The respondent partially disagrees with this finding. There are inherent risks in working with individuals whose behavior may be unstable and unpredictable, whether due to acute intoxication from a variety of substances or from an acute episode of a psychiatric illness. The challenges to fully staff programs and units have only increased during the Covid-19 pandemic and the “great resignation.” This is true locally and statewide. While the County Behavioral Health Department and its contracted providers serve more than 5,000 individuals per year, the number of documented incidents of assault or injury to county or contracted staff are related to a very few individual patients. The goal of any responsible company or department, including the County, is zero assaults or injuries; however, due to both lack of resources, including trained staff, and the increasing acuity of clients overall, the County and its contractors continue to experience some incidents of violence.
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R3:
SLO County should seek the financial resources needed to hire and retain outpatient mental health services professional staff in sufficient number to allow for reasonable and customary management ratios. This recommendation requires further analysis. The Health Agency, in coordination with the County Human Resources Department, will continue to identify and pursue opportunities to recruit and retain qualified staff. This analysis will be followed up within 6 months.
F4:
Despite an almost dizzying array of scheduled interagency, inter and intra-departmental meetings, teams, and working groups, SLO County fails to provide the kind of unified, integrated, and “single” voice leadership needed to ensure that espoused policy regarding the delivery of mental health services in a manner that meets the needs of our community while simultaneously respecting and appropriately protecting the professionals who strive to provide such service. The respondent agrees with this finding. There is no single voice to represent all the needs of the community’s mental health. A range of regulations, scopes, restrictions, and funding streams—in addition to entrenched stigma—contribute to a siloed array of services that can be legitimately confusing for the lay person. Addressing the complexity of this situation is beyond the scope of the County’s responsibility and ability, although the County strives to do its part. The County is responsible under contract with the State Department of Health Care Services for specialty mental health services for SLO County Medi-Cal beneficiaries. The County is also responsible for substance use services for SLO County Medi-Cal beneficiaries. Through a range of grants, short term funding, realignment, County general fund, Medi-Cal reimbursement, and minimal 4 of 52 reimbursement from Medicare for certain services, the County has provided an array of services from prevention and education through treatment and residential care. Similarly, there is no single voice representing the private mental health system, although there is a State Department of Managed Care with the responsibility to ensure that private insurance companies provide mental health services in equity with other medical services.
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R4:
SLO County should seek the financial resources needed to hire and retain mental health services professional staff in sufficient number to meet the needs of Held juveniles within our county. This recommendation requires further analysis. The responsibility of the County is to serve individuals who are Medi-Cal beneficiaries, or who are indigent. The responsibility of the Mental Health Plan, the contracted services between the County and the State Department of Health Care Services, is to pay for medically necessary inpatient care for all SLO County Medi-Cal beneficiaries. SLO County will continue to collaborate with other providers, both locally and statewide, to develop additional services for minors, including a continuum of crisis services. The Interim Health Agency Director has recently convened an Executive Steering Committee to seek collaborative partnerships to further develop resources for all community members requiring psychiatric care. R.5 The SLO County Sheriff’s Office, SLO County Behavioral Health Services, and the SLO County Board of Supervisors should jointly devise and implement a plan to ensure that properly trained and certified correctional officers are assigned in sufficient number to provide for the safety and security of all staff and held persons when such persons are in the County’s care and custody no matter which facility is responsible for the patient. This recommendation item requires further analysis. 2 7 of 52 At this time, the Health Agency contracts with a local security company that has been able to fully staff 2 FTEs of security 24/7 for the PHF and the Health Campus, as directed by the County CAO. Further discussion related to the Sheriff’s Office will be managed by the Interim Health Agency Director. 3 8 of 52 Evaluation Report CORPORATION RYAN K. MCBAIN, JONATHAN H. CANTOR, NICOLE K. EBERHART, SHREYA S. HUILGOL, INGRID ESTRADA-DARLEY Adult Psychiatric Bed Capacity, Need, and Shortage Estimates in California—2021
F5:
SLO County is entirely dependent on private service providers located outside of our County to provide beds and treatment for all Held juveniles and for those adults who don’t fit the criteria for acceptance at the PHF. The respondent agrees with this finding. 5 of 52 COUNTY OF SAN LUIS OBISPO HEALTH AGENCY BEHAVIORAL HEALTH DEPARTMENT Anne Robin, LMFT Behavioral Health Director Response to Recommendations R 1: SLO County should commit to creating a single, integrated, and unified mental health services center that houses the PHF, the CSU, the MHET, outpatient coordination, juvenile mental health services, and that includes a medical health triage and screening facility where all Held persons, regardless of age, categorization, or insurance status, can be medically cleared prior to placement in an appropriate section of the mental health facility. This recommendation has not yet been implemented, but may be implemented in the future. The County Behavioral Health Department fully embraces the concept of a “one stop shop” and a full continuum of care for individuals with psychiatric or addiction care needs. The idea of a multi-service site has been planned as part of the anticipated Health Campus remodel, originally planned for 2024-25. This plan had to be set aside during the Covid-19 pandemic response. Once the Health Campus project is re-initiated, plans to develop a multiple service site will continue. The ability to fund such services to be agnostic of payor (that is, to be available for those with private insurance as well as those with Medi-Cal coverage) would need to be fully evaluated over time. The Mental Health Plan, which is the role of the County Behavioral Health system under contract with the Department of Health Care Services, in coordination with CenCal Health, could develop a unified service for individuals who are SLO County Medi-Cal beneficiaries. Integration, or at a minimum, co- location, of physical and behavioral health care is a goal of the California AIM (Advancing and Innovating Medi-Cal) project to improve Medi-Cal services across the State. Certain restrictions due to current State licensing and regulations limit the ability to have multiple services under one roof or provided by a single agency. One model of co-location, currently existing in Orange County, was only able to be created by having different providers for crisis stabilization, PHF, sobering, physical health screening, etc. At this time, the effectiveness of this project is still being evaluated; however, it provides one model to consider. The County hopes that State and Federal regulations may allow for more flexible implementation of projects such as this. R.2: SLO County should relieve the four private hospitals in our County of the responsibility for warehousing Held persons. The respondent notes that this item requires further analysis. The Health Agency has recently convened a new executive steering committee to develop collaborative approaches to address the impact of psychiatric crisis on the 4 local emergency departments. The Health Agency Interim Director will report on the progress of this committee in 6 months. The County fully recognizes the ongoing and statewide crisis in lack of appropriate resources for individuals experiencing psychiatric emergencies. This crisis is well documented; the attached report from the Rand Corporation provides detail. This crisis is not unique to SLO County. In fact, the length of stay for patients in local emergency departments is roughly on average with that of other hospitals in other parts of the State, even in counties where there are multiple privately operated psychiatric hospitals. The Health Agency complies with Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex or any other protected class County of San Luis Obispo Health Agency 2180 Johnson Avenue | San Luis Obispo, CA 93401 | (P) 805-781-4719 | (F) 805-781-1273 6 of 52 slobehavioralhealth.org Two areas of concern have been the lack of psychiatric hospitals willing or able to accept individuals who test positive for Covid-19. These individuals have ended up remaining in emergency departments statewide for longer period of times than desired. The second area is the lack of pediatric psychiatric facilities, so youth have at times spent multiple days in emergency departments awaiting an appropriate placement. Neither of these situations are beneficial to the patients or their families, but are an unfortunate result of the lack of facilities either in SLO County or statewide to meet the specialized needs of these patients. Addressing this crisis effectively will require the full participation and engagement of multiple local entities, each with a distinct legal responsibility and area for potential impact. The County Health Agency has the responsibility to pay for inpatient treatment for County Medi-Cal beneficiaries. Beyond this legal responsibility, the County has also unilaterally increased services to provide care for individuals in psychiatric crisis. Hospitals with dedicated emergency departments have the responsibility to screen, stabilize, and transfer all individuals who present to their campuses. Responding to this crisis is a shared responsibility and the County is ready to continue working together toward a solution.
Recomendaciones relacionadas (1)
R5:
The SLO County Sheriff’s Office, SLO County Behavioral Health Services, and the SLO County Board of Supervisors should jointly devise and implement a plan to ensure that properly trained and certified correctional officers are assigned in sufficient number to provide for the safety and security of all staff and held persons when such persons are in the County’s care and custody no matter which facility is responsible for the patient. This recommendation item requires further analysis. 2 7 of 52 At this time, the Health Agency contracts with a local security company that has been able to fully staff 2 FTEs of security 24/7 for the PHF and the Health Campus, as directed by the County CAO. Further discussion related to the Sheriff’s Office will be managed by the Interim Health Agency Director. 3 8 of 52 Evaluation Report CORPORATION RYAN K. MCBAIN, JONATHAN H. CANTOR, NICOLE K. EBERHART, SHREYA S. HUILGOL, INGRID ESTRADA-DARLEY Adult Psychiatric Bed Capacity, Need, and Shortage Estimates in California—2021 Summary Psychiatric beds are essential infrastructure for meeting the needs of individuals with mental health conditions. However, not all psychiatric beds are alike: They represent infrastructure within differ- ent types of facilities, ranging from acute psychiatric hospitals to community residential facilities. These facilities, in turn, serve clients with different needs: some who have high-acuity, short-term needs and others who have chronic, longer-term needs and KEY FINDINGS may return multiple times for care. ■ California faces an estimated 1.7-percent growth in its psychiatric bed California, like many parts need from 2021 to 2026. of the United States, is confront- ■ California faces shortages of psychiatric beds at all three major levels ing a shortage of psychiatric beds. of adult inpatient and residential care. This shortage manifests in high ■ Significant regional differences in the estimated shortfall of beds were bed occupancy rates and long wait noted at each level of care. lists for placements. However, determining the primary drivers ■ Growth in the need for psychiatric beds is projected to be largest in the Northern and Southern San Joaquin Valley. of this shortage—accounting for regional variation in psychiatric ■ Hard-to-place populations contribute disproportionately to bottle- bed capacity at different levels of necks in the existing system. care—is a challenging problem to ■ A majority of psychiatric facilities at all levels of care reported an tackle. Nevertheless, California inability to place individuals with comorbid dementia or traumatic brain is committed to expanding the injury, nonambulatory individuals, those requiring oxygen, and those mental health infrastructure, who tested positive for COVID-19. Individuals involved in the criminal justice system were reportedly difficult to place in community residen- including psychiatric bed capacity. tial settings. How, where, and to what extent 9 of 52 these investments should be made remains an open To estimate psychiatric bed need, we used several question. approaches for the purpose of triangulation. First, In this report, we estimated psychiatric bed we contacted psychiatric facilities throughout the capacity, need, and shortages for adults at each of state and spoke with administrative leaders at these three levels of care throughout California. These facilities to quantify bed occupancy rates, wait list three levels of care are acute, subacute, and commu- volume, average length of stay, and the number of nity residential services: individuals whom they would transfer to a higher or lower level of care if able to do so. Using the informa- • Acute care is directed toward those with the tion gathered, we were able to compute the number of highest acuity needs, is typically shorter term beds required—at each level of care in each region of (days to weeks), and is intended to stabilize the state—to reduce occupancy rates to 85 percent (a patients. standard ceiling) and accommodate wait list volume • Subacute care is directed toward those with and requested transfers. We calculated these estimates moderate- to high-acuity needs for a longer excluding state hospitals and, separately, including duration (multiple months). state hospitals, prioritizing the former approach. Our • Community residential services are intended rationale for this is that state hospital beds are gener- to address lower acuity and longer-term ally not considered part of the continuum of care at care (often multiple years) that is focused on a local level in terms of decisionmaking purposes. patient recovery. Second, we moderated this bottom-up estimate We computed these estimates with and without the by incorporating epidemiological information on inclusion of state hospitals, which often provide care regional variation in serious psychological distress for unique subpopulations who may be hard to place in (SPD) among adults, which serves as an indicator of other settings, including those with high acuity, long- psychiatric bed need. Third, as a top-down approach, term needs. Additionally, we projected growth in the we convened a Technical Expert Panel to deliberate need for psychiatric beds in the period of 2021 to 2026. and arrive at normative estimates of psychiatric bed need available from the research literature. Approach Lastly, we projected the need for psychiatric beds in the period from 2021 to 2026. To accomplish this, Our population of interest comprised adults (18 years we first quantified the prevalence of SPD according or older) throughout California. The corresponding to demographic categories (i.e., sex, race/ethnicity, sampling frame contained all psychiatric facilities and age group) among adults in California, using the with psychiatric beds serving adults throughout Cali- California Health Information Survey. From this, fornia’s 58 counties. Because individuals might access we were able to estimate the regional prevalence of psychiatric facilities (and beds) outside their county SPD in 2026, based on evolving demographic trends. of residence, we aggregated estimates at a regional Next, we cross-walked the estimated prevalence of level using the U.S. Census Bureau classification. SPD to the likelihood of requiring inpatient psychi- To estimate psychiatric bed capacity, we synthe- atric services, based on the proportional need for sized an array of data sets from state agencies that inpatient psychiatric services among individuals with are responsible for licensure of psychiatric beds. To versus without SPD, according to the National Survey supplement this information, we employed a strati- on Drug Use and Health (NSDUH). fied randomized sampling approach to administer a survey to collect data on the number of beds at facili- ties and the number of beds occupied. We provided Key Findings estimates to county points of contact at behavioral Psychiatric bed capacity. We estimated that Cali- health departments to review and revise them with fornia has a total of 5,975 beds at the acute level (19.5 an eye to improving accuracy. per 100,000 adults) and 4,724 at the subacute level (15.4 per 100,000 adults)—excluding state hospital 2 10 of 52 beds. If state hospital beds are included, these fig- ures increase to 7,679 (25.1 per 100,000 adults) and 9,168 beds (29.9 per 100,000 adults), respectively. We also observed large regional variation. For example, Growth in the need excluding state hospitals, acute bed capacity ranged for psychiatric beds is from 9.1 beds per 100,000 adults in the Northern San Joaquin Valley to 27.9 beds per 100,000 adults in the projected to be largest Superior region. For subacute bed capacity, regional estimates ranged from 7.4 to 31.8 beds per 100,000 in the Northern and adults. At the community residential level, we esti- mated that California has a total of 3,872 beds (12.7 Southern San Joaquin per 100,000 adults). Psychiatric bed need. Using observed occupancy Valley. rates, wait list volumes, and requested transfers, we estimated that California requires 50.5 inpatient psychiatric beds per 100,000 adults: 26.0 per 100,000 Psychiatric bed shortages. Synthesizing figures for at the acute level and 24.6 per 100,000 at the subacute bed capacity and bed need, we estimated that the state level, or 7,945 and 7,518 beds, respectively. At the has a shortfall of approximately 1,971 beds at the acute community residential level, we estimated a need of level (6.4 additional beds required per 100,000 adults) 22.3 beds per 100,000 adults. and a shortage of 2,796 beds at the subacute level (9.1 Estimated prevalence of SPD in California ranged additional beds required per 100,000 adults)—or 4,767 from 7.9 percent in the San Francisco Bay Area to subacute and acute beds combined, excluding state hos- 9.3 percent in the Southern San Joaquin Valley. When pital beds. If state hospitals were included in this esti- we incorporated this epidemiological information mate, the shortage of acute inpatient beds would shrink into our psychiatric bed need estimates, this intro- to 267, and there would be no observable shortage in duced regional variation in psychiatric bed need that beds at the subacute level. Separately, we estimated a ranged from 45.5 to 55.5 inpatient psychiatric beds per shortage of 2,963 community residential beds. 100,000 adults. Lastly, we collected secondary esti- The top-down estimates of psychiatric bed mates of psychiatric bed need from the academic lit- need—as drawn from the literature and our Techni- erature and our Technical Expert Panel. Using median cal Expert Panel—also indicated a bed shortage: 8.9 values, we generated a separate, top-down estimate beds per 100,000 adults at the acute level and 10.6 of psychiatric bed need: 27.5 beds per 100,000 adults beds per 100,000 adults at the subacute level. There- at the acute level and 25 per 100,000 at the subacute fore, our bottom-up and top-down estimates were level. We were unable to provide a comparable top- closely aligned. The remaining discrepancy likely down estimate of need for community residential beds pertains to differences in the configuration of health because of the significant heterogeneity within this systems throughout the United States and interna- classification and the paucity of academic literature. tionally, including availability of outpatient services We estimate that the magnitude of need for psychi- and alternatives to hospitalization, that drive need. atric beds is expected to grow modestly over the next When regional prevalence estimates for SPD were five years (2021 to 2026): by 1.7 percent. This is primar- incorporated, the gap in beds required reduced mod- ily due to shifting demographic trends, including adult estly: by 4.5 percent. We also documented significant population growth and increasing racial/ethnic diver- regional differences in the estimated shortfall of beds sity, because epidemiological data indicate that His- on the basis of the wide regional variation in psychiat- panic and Black adults experience SPD at higher rates ric bed capacity. For example, two regions of the state than do White adults. Growth in the need for psychi- appear to have sufficient acute inpatient psychiatric atric beds is projected to be largest in the Northern and bed capacity, whereas the remaining eight regions Southern San Joaquin Valley—by about 4.0 percent. 11 of 52 3 have a shortfall. At the subacute level, all regions such regions as the Central Coast, Inland (apart from the Northern San Joaquin Valley) appear Empire, and Southern San Joaquin Valley. to have a shortfall. However, the magnitude of this 2. Consider focusing on building or remodel- shortfall ranges from 5.1 additional beds required per ing infrastructure for the most hard-to-place 100,000 adults in the North Coast region of the state populations. Specific subpopulations appear to 17.2 additional beds required per 100,000 adults in to contribute disproportionately to bottle- the Southern San Joaquin Valley. necks in the current system, including an Lastly, we inquired about hard-to-place popula- inability to transfer patients with criminal tions. Here, we found that a majority of psychiatric justice involvement from the subacute level of facilities at all levels of care reported an inability to care to community residential settings. Given place individuals with comorbid dementia or trau- this, the state might need to consider alterna- matic brain injury, nonambulatory individuals, those tive arrangements for placing such popula- requiring oxygen, and those who tested positive for the tions, such as community-based and outpa- coronavirus disease 2019 (COVID-19). A majority of tient competency restoration programs. Here, respondents from community residential facilities also California could learn from other mental reported an inability to place individuals involved in health systems across the United States and the criminal justice system—particularly those with internationally. arson or sex offense convictions. 3. Set aside state funds for a system that reviews licensure data and periodically collects psychiatric facility–level information. Our Recommendations analysis and conclusions contain numerous Using these findings, we came up with three caveats, in large part because of poor data recommendations: quality. We wish to be transparent about this fact, with the hope that this serves as an impe- 1. Prioritize psychiatric bed infrastructure in tus for the state to consider investing in an the areas with the greatest need. In terms of adequate data review and monitoring system. an absolute shortfall of beds, the shortfall If the state were to allocate funds to routinely was greatest in terms of subacute beds, driven monitor and purge licensure data, policymak- partly by four regions (Los Angeles County, ers would be in a much stronger position to San Francisco Bay Area, Inland Empire, Supe- know what the existing capacity is at each rior region) that represented a shortfall of level of care—particularly at the community more than 2,000 beds—more than a quarter residential level. Likewise, the state should of all additional beds needed throughout the consider establishing a mechanism by which state. If policymakers examine the psychiatric psychiatric facilities report periodically on bed bed shortfall as a proportion of regional adult occupancy rates, wait list volume, number of population, this might lend greater weight to requested transfers to higher and lower levels regions with smaller or more rural popula- of care, and psychiatric patient boarding in tions: For example, the shortfall of subacute emergency departments. The state should also beds is 5.2 beds per 100,000 adults in Los consider collecting sociodemographic and Angeles County compared with 17.2 per clinical information on patients who use psy- 100,000 adults in the Southern San Joaquin chiatric beds. This would allow California to Valley. We also observed significant need for have a remarkably precise and sensitive system acute beds in such regions as the Northern for tracking the impact of investments that and Southern San Joaquin Valley and Central seek to address psychiatric bed shortages. Coast, while the shortfall at the community residential level was particularly notable in 4 12 of 52 Introduction Role of Psychiatric Beds Today, hundreds of Psychiatric beds are essential infrastructure for Californians in need of meeting the needs of individuals with serious mental health conditions.1 These beds serve several psychiatric beds are functions—including enabling safe, stable, and sup- held in hospital EDs or portive environments for individuals in acute mental health crises and for those with significant impair- county jails awaiting ment who require ongoing medical monitoring.2 Not all psychiatric beds are alike, because they openings in inpatient represent infrastructure within different types of facilities. For example, psychiatric beds in acute inpa- care settings. tient hospitals serve those in need of secure, 24-hour care and often include crisis stabilization units. The average length of stay in such states as California is resolution and triage services, acute inpatient ser- one to two weeks.3 By contrast, psychiatric beds in vices, subacute services, state hospitals, and com- such subacute facilities as mental health rehabilita- munity residential services. Clinical guidelines, such tion centers (MHRCs) or special treatment programs as the Level of Care Utilization System, enforced by at skilled nursing facilities (SNFs)—which provide the state of California through Senate Bill (SB) 855 longer-term recovery-oriented services, such as inde- (2020),8 provide a useful compass for matching an pendent life skills training—may remain occupied by individual’s needs with an appropriate level of care. the same individuals for many months.4 Ultimately, psychiatric beds represent an impor- tant component in a continuum of behavioral health Psychiatric Bed Shortfall care that includes integrated community services Psychiatric bed capacity is severely strained in Cali- ranging from prevention and screening to emergency fornia, as it is in much of the United States.9 The crisis response. Depending on the arrangement of present situation may be viewed, in part, as the long services, the need for psychiatric beds may look dif- tail of an effort to deinstitutionalize psychiatric ser- ferent. For example, the CrisisNow model of emer- vices throughout the United States during the latter gency care instituted in Arizona has significantly half of the 20th century: from a peak of 337 psy- reduced the state’s volume of psychiatric emergency chiatric beds per 100,000 individuals in the United department (ED) boarding.5 Assertive Community States in 1955 to a low of around 12 beds per 100,000 Treatment and similar models, such as Full Service in 2016.10 This transition to community-based Partnership programs, may also be key contribu- services—although well-intentioned—has resulted in tors. These models employ transdisciplinary teams a paucity of infrastructure to serve the needs of indi- to provide comprehensive services to patients who viduals who would otherwise benefit from a stable have needs that have not been adequately met by and supervised residence, particularly those with traditional approaches.6 According to the Substance serious mental illness (SMI).11 Abuse and Mental Health Services’ Behavioral Today, hundreds of Californians in need of psy- Health Treatment Services Locator, there are 133 chiatric beds are held in hospital EDs or county jails mental health treatment facilities in California that awaiting openings in inpatient care settings.12 In offer these services, though these services may be addition, a sizable percentage of chronically home- underreported.7 less individuals have an SMI.13 As county jail and With regard to psychiatric beds specifically, homeless populations continue to swell, these rising California embeds psychiatric beds within crisis numbers have created an increasing urgency to take 13 of 52 5 Estimating the need for psychiatric beds is a thorny undertaking. There are no standardized Given the diversity and approaches or best practices, and health systems geographic distribution are constructed differently at the regional and state levels. However, prior literature outlines at least of both adults and four methods for calculating the number of psy- chiatric beds that are needed to address population psychiatric facilities needs. These methods include (1) expert consensus, (2)a normative approach, (3) a population health in California, needs approach, and (4) an observed outcomes approach.16 We briefly survey these approaches, including their throughout the state are strengths and limitations. Expert consensus. Calculating psychiatric bed heterogeneous. need by expert consensus relies on open discussion among content and methods experts—who opera- tionally define a set of relevant principles, deliberate action. For example, in early 2021, an estimated 1,600 evidence, and then achieve mutual agreement on adults in need of psychiatric beds were residing in standards. A key example of this approach is a 2008 county jails because they had been deemed incompe- report by the Treatment Advocacy Center (TAC),17 tent to stand trial and were unable to be placed by the which interviewed 15 experts to deliberate and arrive Department of State Hospitals (DSH).14 Legislators, at a suggested benchmark for measuring psychiatric meanwhile, have called for an overhaul of state psy- bed need: 40 to 60 beds per 100,000 in population.18 chiatric services—particularly against the backdrop of Although expert consensus is a helpful method the COVID-19 pandemic.15 for arriving at an estimate of psychiatric bed need, this approach has limitations. The report by TAC did Measuring Need for Psychiatric Beds not outline the precise deliberations that led experts to arrive at their conclusion, making it challenging Estimating the need for psychiatric beds in Califor- to scrutinize the estimate or replicate the process. nia is essential for at least three reasons. First, when Furthermore, without a set of operational definitions estimates on the need for psychiatric beds are paired for such terms as psychiatric bed, it remains unclear with estimates on the existing bed capacity, evalu- whether a specific benchmark would translate in other ators can determine the magnitude of the shortfall settings or how one would go about allocating 40 to 60 in beds throughout the state, allowing policymak- beds per 100,000 in population across different levels ers to discuss investments accordingly. Second, the of care. The number and types of beds required are estimation process can serve a diagnostic function: liable to depend on local context and resources. Given the diversity and geographic distribution Normative approach. The normative approach of both adults and psychiatric facilities in Califor- to calculating psychiatric bed need is predicated nia, needs throughout the state are heterogeneous. on an assumption that jurisdictions (or countries) Lastly, if the need for psychiatric beds is estimated with similar health systems and demographic char- at multiple intervals, these estimates can provide an acteristics are likely to require a similar number ongoing feedback mechanism for fine-tuning invest- of psychiatric beds. In this scenario, a jurisdiction ments. Because needs are dynamic, investments in with more-robust psychiatric facility infrastruc- infrastructure at any given time may only partially ture has the potential to serve as a comparator for address problems. This factor should create an impe- others. For example, the Organisation for Economic tus to determine how effective initial investments Co-operation and Development has employed this were and to plan for new investments for new needs approach to compare mental health infrastructure have arisen. across its 38 member countries, providing annual- 6 14 of 52 ized estimates of psychiatric beds per 100,000 in for example, the Department of Health used popu- population—with a low of 3 beds per 100,000 in lation and demographic estimates to calculate the population in Mexico to 259 per 100,000 in popula- total psychiatric bed need as 30 beds per 100,000 in tion in Japan (the United States ranks seventh from population.23 Other states (Mississippi, Oklahoma, the bottom at 25 per 100,000).19 The World Health Missouri) have performed similar calculations, using Organization has followed a similar model with its a fixed population ratio to arrive at estimates of need Mental Health Atlas project.20 Coupled with other ranging from 20 to 117 psychiatric beds per 100,000 indicators (e.g., hospital readmission rates), compara- in population.24 This wide range in values is indica- tive analyses can be used to determine whether and tive of disconcerting variation in the parameters used to what extent more-robust infrastructure translates to come up with these estimates. to improved population health outcomes. Calculating the number of psychiatric beds The main challenge with the normative approach needed from this population health approach assumes is that there are large differences in the number of certain targets for specific mental health conditions, psychiatric beds per capita even within countries which may be more or less accurate. For example, that have similar health and economic systems. Fur- there is a paucity of epidemiological data on the likeli- thermore, understanding the difference in reported hood of an individual requiring specific services based numbers of psychiatric beds is difficult because there on mental health diagnosis and illness severity, and on is no standard definition for psychiatric bed. Coun- the optimal duration and intensity of service provi- tries like Italy do not consider residential treatment sion. Relying on limited information risks generating facilities to constitute inpatient care, producing a inaccurate predictions for the number of psychiatric much lower estimate per 100,000 in population com- beds needed and may underpin the wide variation pared with countries that include residential treat- observed in estimates across states—which are often ment facilities.21 Additionally, what works for some using differing sets of assumptions. countries and systems in terms of psychiatric bed Observed outcomes approach. The observed needs and mental health services may not work in outcomes approach is based on the observation that others. Individual countries may first need to define heterogeneous psychiatric bed capacity across coun- their core mental health services and set data-driven ties and states is liable to have observable effects on targets to meet those needs. One recent study found health systems and populations.25 By looking at the that, out of 32 mental health plans developed across relationship between psychiatric bed capacity and key five countries, only four plans included specific tar- performance indicators—such as wait times, occu- gets for their core services—including psychiatric pancy rates, length of stay, emergency room board- bed needs.22 These sorts of comparative metrics are ing, and population health outcomes—researchers also generally lacking within the United States across have the potential to calculate minimum and optimal regions and counties. psychiatric bed capacity requirements from an induc- Population health approach. A population tive perspective.26 Along these lines, in 2020, the San health approach identifies the prevalence of mental Francisco Department of Public Health conducted a health conditions within a geographic area and simulation to assess psychiatric bed need, which ana- then applies a set of standards to meet population lyzed more than 25,000 mental health–related admis- health needs in accordance with these prevalence sions and accounted for variable bed occupancy rates estimates—including quantifying psychiatric services across different levels of care.27 The authors of the and corresponding infrastructure, such as psychi- report concluded that observed bed occupancy rates atric beds. One advantage of this approach is that greater than 85 percent have the potential to contrib- prevalence estimates for particular mental health ute to bottlenecks and flow issues over the long run conditions (and, by extension, needs that derive and suggested an additional 97 beds across four types from these conditions) are sensitive to the underly- of facilities to achieve zero wait time. ing demographic characteristics of the region—such The observed outcomes approach has also been as age, sex, and income distributions. In Tennessee, criticized.28 Specifically, researchers have argued that 15 of 52 7 key performance indicators tend to concentrate on bill’s provisions allow local governments to purchase process measures pertaining to hospital administra- psychiatric facilities to prevent closures and require that tion, which may have little correspondence to patient facility owners give residents greater advanced notice outcomes. Furthermore, hospital functioning may be prior to closure. Several complementary bills signed into dependent on a wide array of factors, such as employ- law earlier this year, including AB 27, AB 362, AB 816, ment rates or social determinants of health within AB 977, AB 1220, AB 1443, and SB 400, represent part the local community. Therefore, these extraneous of a $22 billion investment to address homelessness and factors may function as confounders during analysis the need for behavioral health services. The investments unless they are incorporated as covariates. include $3 billion dedicated to housing for those with Ultimately, as noted earlier in this report, there are acute behavioral and physical health issues—with an no consensus best practices for determining psychiat- expectation of creating approximately 22,000 new beds ric bed needs. The most robust approach may therefore and treatment slots.33 be to inspect the problem from multiple vantage points Additional Assembly legislation, AB 2265, has and methodologies to converge on a triangulated set of focused on increasing access to treatment by allow- estimates for psychiatric bed needs. This includes—to ing California counties to use mental health services the extent possible—pressure testing the approaches funds to address not only mental health conditions outlined above by performing sensitivity analyses. but also substance use disorders, with the goals of We have therefore elected to assume this triangulated enhancing care coordination and creating an inte- approach in our analysis, as further described in the grated behavioral health care system.34 In the context “Methods” section. of psychiatric bed infrastructure, this legislation is particularly relevant for populations in need of longer-term rehabilitative services who are coping California’s Investment in Infrastructure with comorbid substance use and mental health con- California has stated a commitment to expand mental ditions. It was signed into law on September 24, 2020. health infrastructure, including psychiatric bed capacity.29 In early 2020, the California Mental Health Purpose of This Report Services Authority (CalMHSA) announced the forma- tion of a Behavioral Health Task Force, appointed to In this report, we provide an estimate of current advise Governor Newsom on efforts to reform and psychiatric bed capacity throughout the ten census advance behavioral health services throughout the regions of California, according to three overarching state.30 Since the onset of the COVID-19 pandemic levels of care: acute inpatient care, subacute inpa- in 2020, Newsom has signed numerous bills into law tient care, and community residential treatment. We that aim to increase Californians’ access to mental then compare the measure of current psychiatric health services. As noted earlier in this report, these bed capacity with estimates of psychiatric bed need. bills include SB 855, which requires commercial health Lastly, we project bed capacity needs over the next insurance plans outside Medi-Cal to provide medically five years, based on evolving demographic trends necessary treatments for all mental health conditions throughout the state. and substance use disorders.31 The bill also requires We note that the primary bed estimates provided that health plans provide services that comply with in this report do not include state hospitals, although level of care determinations as outlined in the Level of we provide secondary estimates for which state hos- Care Utilization System, American Society of Addic- pitals are included. This decision was based on three tion Medicine criteria, and other clinical guidelines for factors. First, more than 90 percent of psychiatric pediatric populations. beds at state hospitals are occupied by individuals Separately, Assembly Bill (AB) 2377—which was involved in the criminal justice system.35 Thus, state also ratified in 2020—sought to mitigate the impact of hospitals serve a set of clients with unique constraints adult residential facility closures and help residents at that do not apply to local behavioral health con- risk of homelessness in California.32 Specifically, the tinuums that we examine in detail throughout this 8 16 of 52 report. In addition, the forensic population census ization of these facilities and portfolio of services may has continued an upward trend that portends a con- vary. Given this factor, we assigned facilities to three tinued reduction in beds available for non-forensic levels of care—matching closely to a conceptual model individuals. Second, the exclusion of state hospitals established by the County Behavioral Health Directors has the secondary benefit of modeling need for psy- Association of California.37 The levels were defined by chiatric beds if state hospitals were transitioned to two axes: first, the acuity of need being attended to, local, community-based alternatives. Third, unlike ranging from emergent crises to nonemergent, ongo- other types of facilities, state hospitals are not broadly ing supports; second, typical length of stay, ranging distributed throughout the state. This distribution from short term (days to weeks) to long term (months results in computational challenges for determining to years). With the exception of community residen- psychiatric bed shortages in regions that contain state tial facilities, length of stay is usually time-delimited hospitals, especially because not all patients within according to the particular type of facility. state hospitals are residents from the region in which Operationally, we defined the three levels of care that state hospital is located. We discuss further as follows: details in the “Methods” section. 1. acute, representing highly structured, around- We supplement these quantitative analyses with the-clock medically monitored inpatient care input from our panel of technical experts. Using the for individuals at heightened risk of harm to combined results, we outline a series of recommenda- themselves or others, or those who are other- tions. These recommendations pertain to the expan- wise unable to care for themselves sion of psychiatric bed capacity to address existing 2. subacute, representing around-the-clock gaps, and they are situated in California’s context of inpatient care that includes specialized pro- ongoing legislative efforts to establish a holistic con- gramming in a controlled environment with a tinuum of behavioral health care services. significant degree of supervision but with less intensive medical monitoring and interven- tion than acute care Methods 3. residential, representing nonhospital pro- Population and Scope grams in which individuals live on the prem- ises of a facility and are provided with consis- Our population of interest comprised all adults (18 tent programming to promote interpersonal years or older) in California, across all 58 counties. and independent living skills, with staff pres- Because individuals may access psychiatric facili- ent 24 hours a day, seven days a week. ties (and beds) outside their county of residence, we Table 1 details the types of facilities contained aggregated estimates of population, capacity, and within each of these levels of care, based on facility need at a regional level using the U.S. Census Bureau licensure information. classification: Superior California, North Coast, San State hospitals represent a unique type of institu- Francisco Bay Area, Northern San Joaquin Valley, tion. In other settings, acute care is short term and Central Coast, Southern San Joaquin Valley, Inland focused on stabilizing patients, whereas residential Empire, Los Angeles County, Orange County, and San Diego-Imperial.36 Although our denominator for care is lower intensity and geared toward long-term medical and nonmedical supports.38 In this sense, the calculations in this report included all adults in the two axes described above (acuity and length of California—because all adults have the potential to stay) are aligned. The expectation is that patients may use inpatient psychiatric services—a disproportion- transition up and down the care continuum based ate number of those using psychiatric beds are adults on their needs at a given time point. However, state with SMIs, such as schizophrenia, bipolar disorder, hospitals are less dynamic and often provide care for and major depressive disorder. subcategories of patients with long-term, high acuity There are many types of psychiatric facilities in needs or based on medical necessity. For example, California. Depending on the county, the character- 17 of 52 9 TABLE 1 individuals who are incompetent to stand trial and are Levels of Care and Corresponding Adult awaiting transfer to an alternative care setting such Psychiatric Bed Infrastructure as a state hospital.42 Our rationale for this was that, although jail units are not suitable to serve as psychiat- Level of Care Types of Facilities Included ric beds (and therefore should not factor into capacity), Acute Acute psychiatric hospitals; psychiatric they are nevertheless housing individuals in need of (Level 3) health facilities; general acute care psychiatric beds. This was not possible for ED board- hospitals with psychiatric wards; acute beds at state hospitals ing. Although California generates an annual hospital utilization report, these reports do not contain ED Subacute General or specialized subacute facilities; (Level 2) MHRCs; SNFs with specialized treatment boarding rates among patients with mental health con- programs; institutions for mental disease; ditions.43 Likewise, there are no formal tallies of the subacute beds at state hospitals number of individuals with mental health conditions Residential Adult residential treatment facilities; who are receiving permanent supportive housing and (Level 1) enhanced or augmented board-and-care facilities; social rehabilitation facilities would otherwise benefit from alternative placement in a setting with psychiatric beds. NOTE: For a definition of psychiatric health facilities, see California De- partment of Health Care Services, 2021b. For a definition of institutions for mental disease, see California Department of Health Care Services, 2021c. Procedures state hospitals often house forensic patients (i.e., Focus group discussions. As a preliminary step, those involved with the criminal justice system), and, we conducted focus group discussions with county in California, many state hospital beds are reserved leaders at behavioral health departments throughout for such patients.39 This raises two questions: Should the state and members at CalMHSA and the County state hospitals be placed within the care continuum; Behavioral Health Directors Association. These and, if so, where? For the purposes of this report, we discussions focused on conceptual issues that these have remained agnostic to the first question, com- individuals were confronting with regard to sup- puting capacity and bed shortages with and without porting psychiatric bed needs. We focused on four inclusion of state hospitals. For the latter, we allo- topics: (1) perceived structural drivers of psychiatric cated acute state hospital beds to the acute level and bed shortages, (2) populations who were challenging subacute beds to the subacute level, both of which are to place in psychiatric facilities, (3) defining the care documented in licensure data sets.40 continuum, including which types of facilities cor- Specific populations and bed categories were respond to which levels of care, and (4) other areas deemed to be outside the scope of our analysis. of note that would be important for RAND research- Regarding populations, we excluded children and ado- ers to consider. We took detailed notes from each lescents, for whom there are subtle but important dif- discussion and deliberated the feedback provided to ferences in the care continuum and who were therefore us to develop our methodological approach, which is deemed to merit a separate analysis.41 Regarding bed detailed below. categories, we omitted beds corresponding to perma- Estimation of capacity. We downloaded the nent supportive housing, those in county jails, and most current licensure data available for each type those in EDs used for boarding patients with mental of psychiatric facility, using public data sets from health conditions. These categories are seldom quanti- the California Department of Public Health,44 Cali- fied as psychiatric beds because they are not exclu- fornia Department of State Hospitals,45 California sively reserved for populations with mental health Department of Health Care Services,46 and Cali- conditions, though it may be the case that individuals fornia Department of Social Services.47 These data with mental health conditions occupy one of these bed sets were then merged into a master file of facilities types. with psychiatric beds in California, and each facility For quantification of psychiatric bed need, we was geocoded at the address and county levels using incorporated the number of jail units occupied by ArcGIS Desktop 10.8.48 10 18 of 52 To validate facility licensure data, we executed need. In total, the Technical Expert Panel consisted two additional steps. First, we contacted behavioral of four participants whose names and titles can be health directors in all 58 counties in October 2021, found in Appendix B, alongside all major prompts providing them with an inventory of facilities within used during the panel’s discussion. their county and soliciting revisions. Where discrep- Estimation of need, Approach 3: population ancies arose, we prioritized the revisions detailed health assessment. Lastly, we drew from epide- by the county point of contact. Second, we reviewed miological data reported in the California Health 2,500 online entries for community residential Information Survey (CHIS) and NSDUH.50 Both the facilities to estimate the percentage of these facilities CHIS and NSDUH employ the Kessler 6, which is a within each county that provided services to indi- measure of psychological distress.51 A score of 13 or viduals with mental health conditions rather than greater indicates SPD, which is a marker of probable those with other types of disabilities or the elderly. SMI. This allowed us to rebalance regional need for For example, if we queried 60 community residential psychiatric beds based on (1) estimated regional prev- facilities in Orange County and found that 5 of 60 alence of SPD among adults, according to the CHIS, were psychiatric facilities with psychiatric beds, we and (2) expected utilization of psychiatric inpatient inferred that this percentage (5/60 = 8.3%) applied services among adults with versus without SPD in at the population level—that is, that 8.3 percent of the United States, based on NSDUH (which contains Orange County’s community residential facilities and estimates of self-reported receipt of inpatient mental beds were psychiatric facilities that contained psychi- health services in the past year).52 A substantial body atric beds. of literature has shown that SPD is a correlate of SMI Estimation of need, Approach 1: survey of and that those with SPD have a greater need for both psychiatric facilities. Using the observed outcomes outpatient and inpatient services.53 approach described earlier in this report, we drew a Projection of need. In addition to estimat- random sample of psychiatric facilities throughout ing current need for psychiatric beds, we projected California using Stata’s v.17 runiform command49 change in need over the next five years (2021 to and attempted to contact facility directors to inquire 2026). These estimates drew from expected trends about bed occupancy, average length of stay, wait in population growth and demographic shifts in the list volume, and the number of patients that facility age, sex, and racial/ethnic composition of the state directors recommended for transfer to a higher or according to U.S. Census Bureau information. The lower level of care. In the event that we were unable “Analysis” section provides a fuller description of the to reach an administrative leader at a particular facil- computations involved in this. ity, we made up to four additional attempted con- tacts per facility. For facilities that we were unable to Measures reach, we imputed estimates based on median values within the facility type and county, adjusting for total Psychiatric beds. We defined psychiatric beds as number of beds. Calls were made in October and beds within psychiatric facilities that have the pri- November 2021.
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Hallazgos & Recomendaciones
2 hallazgos
F1:
I (we) agree with the findings numbered: __ F1, F4, F6
Recomendaciones relacionadas (1)
R1:
All Cemetery Districts should provide ways to accept current forms of payments. The County has established ways to pay property taxes and other fees using alternate methods of payment for their charges. The Cemetery Districts should investigate how they could link to that payment method.
F2:
I (we) disagree wholly or partially with the findings numbered: F2, F3,F5,F7,F8,F9,F10,F11,F12 (Attach a statement specifying any portions of the findings that are disputed; include an explanation of the reasons.)
Recomendaciones relacionadas (1)
R2:
Direct the Clerk of the Board to forward the responses to the Presiding Judge and the Grand Jury by August 23, 2022.
Recomendaciones adicionales
4
No vinculadas a hallazgos específicos.
R3:
Recommendations numbered require further analysis. (Attach an explanation and the scope and parameters of an analysis or study, and a timeframe for the matter to be prepared for discussion by the officer or director of the agency or department being investigated or reviewed, including the governing body of the public agency when applicable. This timeframe shall not exceed six months from the date of the publication of the Grand Jury report.)
R4:
Recommendations numbered R1 and R7 will not be implemented because they are not warranted or are not reasonable. (Attach an explanation.) Date: 7/ 21/202 2 Signed: Number of pages attached: 1 COUNTY OF SAN LUIS OBISPO Office of James W. Hamilton, CPA Auditor-Controller Treasurer-Tax Collector Public Administrator Michael Stevens, Deputy Justin Cooley, Deputy MEMORANDUM To: SLO County Grand Jury From: Jim Hamilton, ACTTCPA Date: 7/21/2022 Subject: Responses to 2022 Cemeteries Report
R5:
– The Office of County Counsel is assisting the Estrella Cemetery District with clearing title to their property. It is hoped that such title will be cleared by the end of 2022.
R7:
The Board of Trustees should review their Cemetery District’s policy on stipends in regard to the State of California Social Security Administrator letter on taxing of payments to Trustees (See Attachment #1).
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Hallazgos & Recomendaciones
4 hallazgos
F2:
- Partially Disagree: It is noted the allocation of 'nearly 40%' does fluctuate, depending on the amount of drought buffer held by subcontractors.
Recomendaciones relacionadas (1)
R2:
- County Public Works: There have been increases in charges related to "administration and accounting", as the State Water system has seen increased new and important work efforts over the last decade. There are three "Levels" of State Water Project (SWP) Project Administration and Accounting work for the District - 1) District, 2) Central Coast Regional, and 3) State. The following list is a sample of work related to the State Water system: District Level - Subcontractor coordination o Delivery operational coordination, tracking/reporting of annual delivery requests, and processing of requested changes mid-year. o Subcontract updates or inquiries on supply availability or management options (e.g., Processing of drought buffer requests) State Water Subcontractors Advisory Committee Bi-monthly committee meetings to review SWP water supply and delivery operations 0 and to discuss updates/ongoing matters that pertain to the management of the supply - matters that pertain to the District's administration of the contracts. Responding to public inquiries related to the SWP water system or SWP supply use or availability. Utilities Division/Finance Division staff support for Department of Water Resources (DWR) and Central Coast Water Authority (CCWA) invoicing to facilitate District/Subcontractor reimbursement of SWP costs. District planning/coordination efforts related to full allocation of SWP water – i.e., to fully utilize the "excess" (unsubscribed) SWP allocation, for current Subcontractors and also local agencies who are not subcontractors but exploring possibility of utilizing District's available SWP supplies (e.g., Cal Poly, Los Osos Community Services District, local Groundwater Sustainability Agency needs, local drought mitigation needs, etc.) - Coordination with County Operations Center - hub for untraditional uses of District's SWP (e.g., O'Connor Fill Station to address local emergency needs) Regional planning efforts (District's Regional Resiliency Planning Study 2020-2021; Water Management Tools Study with CCWA 2020-2022) Central Coast Level SWP Operations Management Coordination w/CCWA Coordination of local delivery operations and reporting/review (ongoing, routine) with CCWA, occasional participation at their Board or Operating Committee meeting to address questions, speak to issues, or coordinate on operations (e.g., operations staffing and agency coordination/planning to address COVID-19 or local delivery needs during operational changes or maintenance shutdowns). Coordinated review of DWR's SWP Coastal Branch operation financials with Ernst & Young, an independent 3rd party auditor. Completion of a Water Management Tools Study (2020-2022), coordinated with CCWA to understand new management opportunities based on the flexibility provided in the proposed WMT Amendment that would allow the District and CCWA to maximize the benefits of SWP water supplies for the Central Coast (service areas covering San Luis Obispo and Santa Barbara Counties ). Development of a water exchange agreement with CCWA / Santa Barbara County during the 2015-16 drought years; and again, during the 2021-22 drought years – to provide SLO County & Santa Barbara Counties with the ability to use SWP water for local drought mitigation. State Level SWP Project Coordination/Representation for SLO District with State Water Contractors (SWC) & DWR - state-wide coordination, inter-agency review/monitoring of SWP Project operations - SWC-DWR Water Operations Committee – monthly (Dec – May), unless otherwise needed (e.g., for drought coordination). Wet weather delivery operations coordination (2017, 2019 - San Luis Reservoir spill / Article 21 water requests) Drought operations/coordination with SWC/DWR (2012-2016; 2020-2022) SWC-DWR Audit-Finance Committee for SWP Operations – monitoring/tracking of project financials (capital and O&M costs), annual operational priorities, energy costs & considerations (e.g., annual Statement of Charges determination and billing to Contractors; 2017 Oroville Spillway Incident – repair costs and FEMA reimbursement considerations) (District participation on an as-available/as-needed basis). - SWC Monthly coordination meetings with the SWP Contractors at large. Informational updates on DWR and SWC initiatives to operate and maintain the project responsibly, protect water rights, and monitor/coordinate on SWP priorities/policy considerations. (District participation on an as-available/as-needed basis) SWC Board meeting (monthly) - for tracking of SWC board action items, policy decisions/priorities, initiatives, financial considerations. (District participation on an as-available/as-needed basis) Delta Conveyance Project Participation District representation, and monitoring/tracking of the negotiated principles for a 0 contract amendment to support a potential project envisioned to protect/preserve the long-term SWP water supply by addressing the known seismic and environmental/climate risks associated with reliance on the Delta for conveyance. (2018 - 2020) 0 District representation and monitoring/tracking of the DWR planning/design and environmental review effort aimed at defining a potential Delta Conveyance project; participation in planning/environmental review effort keeps option open for the District to decide later on long-term participation once environmental review is completed and a project has been defined. (2021 – current) - Development of Water Management Tools (WMT) Amendment District representation, and monitoring/tracking of the negotiated principles for the contract amendment aimed at improving the flexibility Contractors have in managing their SWP water supplies - with a focus on water transfers and exchanges within the SWP service area. (2018 - 2021)
F3:
– Partially Disagree: References to 'the County' should be replaced with the "San Luis Obispo County Flood Control and Water Conservation District" or "District".
F4:
– Partially Disagree: The administrative charges to the State Water Tax Fund have increased 429% from Fiscal Year 2003-04 actual charges to Fiscal Year 2021-22 final budget. The most recent year of actual data, Fiscal Year 2020-21, reflects a 244% increase in administrative charges from Fiscal Year 2003-04. The actual charges for Fiscal Year 2021-22 will not be known by the District until late August 2022.
Recomendaciones relacionadas (1)
R4:
– County Tax Collector and County Public Works: The County and Flood Control District concur with this recommendation so long as the water resource project has a State Water nexus and will implement when appropriate.
F5:
- Partially Disagree: Property tax revenue for State Water have increased, but the ad valorem rate has remained constant since approximately fiscal year 2013/14. Costs have risen due to increased management efforts, maintenance of the system and a reduced amortization schedule for paying project related costs back to the Department of Water Resources. Currently costs are only amortized until the end of the State Water contract which is 2035. Staff is bringing a contract extension to the year 2085 before the Board of Supervisors for approval on July 12, 2022, which will ameliorate the cost burden to rate payers as any project related costs can be amortized over a longer contract period. Attachment on Recommendations
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Hallazgos & Recomendaciones
20 hallazgos
F1:
CMC offers a broad range of educational, vocational, and rehabilitative services for inmates.
F2:
Recent significant investments by the State of California in both facilities and in specialized services make it unlikely that CMC will be on the list of California correctional facilities slated for closure in the coming years. SAN LUIS OBISPO COUNTY JAIL
F3:
The San Luis Obispo County Sheriff’s Office Main Jail and other detention facilities are staffed by sworn personnel who have self-selected for a career in corrections.
F4:
The Main Jail has experienced a 42% increase in the number of inmates categorized as having serious mental health issues (for both 2020 and YTD 2021). The percentage of inmates in the Jail with serious mental health issues has doubled since the onset of the COVID-19 Pandemic.
F5:
The Sheriff’s Office conducts regular assessments and reassessments of inmate behavior to ensure that individual inmates are housed appropriately and in the least restrictive environment consistent with their current risk profile.
F6:
A discernable dynamic tension exists between staff at the SLO County Main Jail and staff at the SLO County PHF around issues related to PHF staff safety and security when an inmate is transferred from the Main Jail to the PHF.
Recomendaciones relacionadas (1)
R1:
Work collaboratively with the PHF and the County Administrative Officer to ensure staff and patient safety and security when inmates are released into the care of the PHF and explore the possibility of having the Jail designated as a PHF (with appropriate staff) so that inmates with a high potential for violence who are experiencing mental health issues can be treated at the Jail.
F7:
The reduction of inmates eligible for assignment to the Honor Farm means fewer inmates are eligible to do more work related to food, laundry, maintenance, and other essential services.
Recomendaciones relacionadas (1)
R2:
Articulate and publish data on what constitutes a reasonable workload for Honor Farm inmates who provide essential services such as food service, laundry service and maintenance, along with a plan to provide supplemental employees when such workloads are exceeded due to lack of eligible inmates.
F8:
Proximity of the SLO County Safe Parking Area immediately adjacent to the Honor Farm fence creates safety and security concerns for staff and inmates.
Recomendaciones relacionadas (1)
R3:
Move the SLO County Safe Parking Area to a location that is not near the Honor Farm or other areas where incarcerated persons live and work. SAN LUIS OBISPO COUNTY JUVENILE HALL
F9:
Nearly every aspect of Jail operations has been affected and changed in some way due to the many and varied impacts of the COVID-19 Pandemic. JUVENILE HALL
F10:
Juvenile Hall is currently operating well below its capacity.
Recomendaciones relacionadas (1)
R4:
Actively promote SLO County Juvenile Hall as a resource for other California Counties on a fee-for-service basis.
F11:
There is space available within the Juvenile Hall facility for new rehabilitative programs. HOLDING CELLS
Recomendaciones relacionadas (1)
R5:
Proceed with plans and secure funding to create a welding studio and a teaching kitchen to provide educational and vocational opportunities for incarcerated youth. HOLDING CELLS
F12:
As inmate populations continue to grow, additional space will likely be needed at the SLO County Courthouse holding cells. SAN LUIS OBISPO COUNTY CORONER’S FACILITY
Recomendaciones relacionadas (1)
R6:
Explore options for additional or reconfigured space to support the SLO County Courthouse holding cells and related functions. SAN LUIS OBISPO COUNTY CORONER’S FACILITY
F13:
The Coroner’s facility appears to be operating at maximum capacity while the caseload appears to be growing year-over-year. Current spaces are likely not sufficient if current trends continue. PSYCHIATRIC HEALTH FACILITY (PHF)
Recomendaciones relacionadas (1)
R7:
Complete the recommendations of the prior Grand Jury related to facilities expansion and add a standby or backup generator to protect the refrigeration system in case of power outage. SAN LUIS OBISPO COUNTY PSYCHIATRIC HEALTH FACILITY (PHF)
F14:
SLO County has been unable to meet its commitment to providing around-the-clock security at the PHF.1
Recomendaciones relacionadas (2)
R8:
Require contract security to meet its obligation to provide 24/7 security guard presence, to include during meal breaks.
R10:
Develop and implement a plan to relieve PHF staff of the collateral duty to transport patients from area hospitals to the PHF or to out of County locations. SAN LUIS OBISPO COUNTY DISPATCH CENTER
F15:
Although well-trained and competent in the discharge of their duties, staff at the PHF do not feel safe and secure in their work environment.
F16:
The required co-mingling of jail inmates with non-justice system involved individuals creates safety and security risks for PHF staff and patients. Subsequent to this Finding, SLO County Behavioral Health advised the Grand Jury that a second security company was engaged to fill open shifts and that the County is in the process of changing contractors. SAN LUIS OBISPO COUNTY DISPATCH CENTER
Recomendaciones relacionadas (1)
R9:
Develop and implement a plan to segregate inmates from non-justice system involved persons in the care of the PHF and to provide better security for inmates while at the PHF.
F17:
Despite comprising the majority of the workforce, women assigned to the SLO County Dispatch Center are provided with restroom facilities significantly smaller than their male counterparts.
Recomendaciones relacionadas (1)
R11:
Develop a plan to remediate the gender equity issue deriving from the facility retrofit that reduced the size of the women’s restroom facilities.
F18:
A lack of available facilities necessitates the parking of a large travel trailer converted into a locker room that occupies needed parking spaces in a lot shared by several departments.
Recomendaciones relacionadas (1)
R12:
Develop a plan to incorporate locker room facilities into the main building occupied by the Dispatch Center so available parking areas are restored and so staff is not exposed to inclement weather between the locker room and the workplace. SAN LUIS OBISPO COUNTY SHERIFF’S OFFICE PROPERTY ROOM
F19:
The vast majority of the facility housing the Dispatch Center is occupied by the County Office of Emergency Services, a tenant only in residence during major emergencies. SLO COUNTY SHERIFF’S OFFICE PROPERTY ROOM
F20:
The Property Room is at 95% capacity. COMMENDATION The Grand Jury commends the San Luis Obispo County Sheriff’s Office for taking the initiative to create the Behavioral Health Unit within the Main Jail in response to the challenge of providing services for inmates experiencing mental health issues. In particular, we commend the Sheriff for securing more than $290K in private donations which covered the total cost of construction for this very worthwhile project.
Recomendaciones relacionadas (1)
R13:
Develop a plan to expand the capacity of the Property Room, possibly by annexing the contiguous Marine Division spaces.
Hallazgos & Recomendaciones
5 hallazgos
F1:
SLO County has failed to create and maintain a safe, orderly, effective and efficient means for ensuring that persons experiencing mental health issues receive the care they need, when they need it. The average and sometimes extended time periods Held persons spend in local emergency rooms prior to placement in an appropriate treatment facility is unacceptable as demonstrated by records from multiple emergency room encounters.
Recomendaciones relacionadas (1)
R1:
SLO County should commit to creating a single, integrated and unified mental health services center that houses the PHF, the CSU, the MHET, outpatient coordination, juvenile mental health services, and that includes a medical health triage and screening facility where all Held persons, regardless of age, categorization or insurance status, can be medically cleared prior to placement in an appropriate section of the mental health facility.
F2:
By relying on the four private hospital emergency rooms as the primary point of intake for persons experiencing mental health issues, SLO County has created a situation in which the quality and capacity of other emergency medical care within our county is at constant risk of degradation due to a variety of factors all relating to the requirement that those hospitals provide psychiatric services as primary care facilities for which they have little or no dedicated expertise or resources.
Recomendaciones relacionadas (1)
R2:
SLO County should relieve the four private hospitals in our County of the responsibility for warehousing Held persons.
F3:
SLO County does not provide adequate resources to ensure the safety and security of both County and contractor staff who work in mental health services facilities and hospitals based on documented incidents.
Recomendaciones relacionadas (1)
R3:
SLO County should seek the financial resources needed to hire and retain outpatient mental health services professional staff in sufficient number to allow for reasonable and customary caseload management ratios.
F4:
Despite an almost dizzying array of scheduled interagency, inter and intra-departmental meetings, teams, and working groups, SLO County fails to provide the kind of unified, integrated, and “single” voice leadership needed to ensure that espoused policy regarding the delivery of mental health services in a manner that meets the needs of our community while simultaneously respecting and appropriately protecting the professionals who strive to provide such services.
Recomendaciones relacionadas (1)
R4:
SLO County should seek the financial resources needed to hire and retain mental health services professional staff in sufficient number to meet the needs of Held juveniles within our county.
F5:
SLO County is entirely dependent on private service providers located outside of our County to provide beds and treatment for all Held juveniles and for those adults who don’t fit the criteria for acceptance at the PHF.
Recomendaciones relacionadas (1)
R5:
The SLO County Sheriff’s Office, SLO County Behavioral Health Services, and the SLO County Board of Supervisors should jointly devise and implement a plan to ensure that properly trained and certified correctional officers are assigned in sufficient number to provide for the safety and security of all staff and Held persons when such persons are in the County’s care and custody no matter which facility is responsible for the patient.
Hallazgos & Recomendaciones
9 hallazgos
F1:
SLO County moved quickly to establish vaccination capacity well in advance of receiving the COVID-19 vaccine. During the first months when the vaccine was available, the County’s per capita vaccination rate was one of the highest among the counties the Grand Jury sampled.
F2:
SLO County maintained local COVID-19 vaccination records and reconciled that information with the State’s data in CAIR to keep it accurate and current.
F3:
SLO County made dissemination of information to local citizens and to the County’s seven cities and other government agencies a high priority as evidenced by: • developing and maintaining the ReadySLO.org and emergencyslo.org websites • having frequent press briefings • making daily phone calls to leaders throughout the County
F4:
SLO County staff was knowledgeable in vaccination response.
F5:
Strong County leadership took responsibility for pandemic response.
F6:
Periodic emergency response drills conducted before the pandemic were beneficial.
F7:
The County effectively mobilized its Medical Reserve Corps.
F8:
The County’s pandemic response effort has taken a toll on County staff and mental health professionals.
Recomendaciones relacionadas (2)
R1:
SLO County should conduct lessons-learned evaluations with input solicited from all who participated in its COVID-19 vaccination response. The County should document what went right and what could be improved in its pandemic response with an eye toward continuous improvement and being better prepared for the next major community health threat.
R4:
SLO County should proactively provide as-needed Mental Health services to employees who experienced stress as a result of responding to the COVID-19 Pandemic.
F9:
The first effort to register eligible residents for vaccinations was overwhelmed by both the sheer number of people and the lack of vaccine from the State of California. The County acted quickly to rectify the situation and implement an effective, efficient system.
Recomendaciones relacionadas (3)
R1:
SLO County should conduct lessons-learned evaluations with input solicited from all who participated in its COVID-19 vaccination response. The County should document what went right and what could be improved in its pandemic response with an eye toward continuous improvement and being better prepared for the next major community health threat.
R2:
SLO County should review existing emergency plans for mass vaccination events to ensure that lessons learned from the COVID-19 response are incorporated wherever appropriate.
R3:
SLO County should develop a process to periodically educate the public regarding County response to the next public health emergency.