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County Supervisors To Vote To Close Gaps In Programs For Severely Mentally Ill

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County Vote Mentally Ill Program

There may be as many as 10,000 people living in San Diego County with severe mental illness who don’t know they are sick.

In the worst cases they are a danger to themselves and others. They wind up cycling in and out of jails and prison, in and out of emergency rooms, on drugs and living on the streets of San Diego County.

County To Vote On Possible Program For Mentally Ill
Guests: Alfredo Aguirre, Mental Health Director for San Diego County’s Department of Health and Human Services Dr. Michael Plopper, Chief Medical Officer of Sharp HealthCare Behavioral Health Services James “Diego" Rogers, Clinical Director, with the Community Research Foundation.

SAUER: There may be as many as 10,000 people in San Diego County suffering from severe and mental illness and they don't know they're sick. Many of them are falling through holes in the public safety net that's intending to help them. In the worst cases, they end up cycling in and out of the prison system, on drugs, and living on the streets of San Diego County. The county's health and human services is in the process of reviewing the services available to people living in the county who are severely mentally ill and resistant to treatment. Joining me to talk to talk about the services are Alfredo Aguirre, the mental health director for San Diego County's department of health and human services. Welcome. AGUIRRE: Good afternoon. SAUER: And Dr. Michael Plopper is the chief medical officer for Sharp Hospital behavioral health services. PLOPPER: Hello. SAUER: And James Diego Rogers is Clinical Director with the Community Research Foundation. Welcome. ROGERS: Good afternoon. SAUER: What responsibility does San Diego County have to help people who are mentally ill and resistant to treatment and don't have ability to pay? AGUIRRE: We are really the safety net service system for people with persistent and serious mental illness. And we through various providers provide services to over 41,000 adults in this community. And certainly over the years we have developed a number of programs that begin to address the issue of people not accepting treatment. And there's various reasons why people don't accept treatment. Certainly James Rogers, Dr. Plopper can elaborate on that. But our goal is to make the connection, following people out of hospitals the best we can to work with other key partners to engage individuals and their families. SAUER: And what programs and services are offered by San Diego County for people who are mentally ill and refuse treatment? AGUIRRE: We historically over the last -- since 2004 and earlier, we developed a model called assertive community treatment model. It's now known as full-service partnerships. And James can elaborate more on that program. But basically these programs were designed to engage people that were being underserved or unserved. These are individuals who have multiple hospitalizations, who are homeless, at risk of homelessness, and a lot of people that frequented the hospital where doctor Plopper works, we are now serving those individuals and keeping them out of institutions. So we serve 1,100 people through eight core partnerships based on this model. We have expanded services. I can go on and on about the psychiatric emergency response team which is in tandem with law enforcement that works with individuals that are in a crisis and helps actually sometimes avoid a hospitalization and connect them to services they need. SAUER: All right. And James, how successful -- I'm sorry, how successful have you been in getting people who are resistant to treatment to get into these county-funded treatment programs? ROGERS: We've experienced quite a bit of success through our full-service partnership programs. We utilize high fidelity housing first and assertive community treatment models. And it's a multidisciplinary team that goes out to reach the most severe cases of mental illness. And they also have long histories of hospitalizations and living with homelessness. So we've been able to see results through the aggressive outreach, see individuals concretely go from being homeless one day to having an apartment or housing the following day. And then the mental health services are delivered in the community where the client is residing or out on the streets bringing the psychiatrists to them, the clinicians to them so they can receive those services. SAUER: All right. And Dr. Plopper, what role does Sharp play in treating this situation? PLOPPER: At Sharp Mesa Vista, we have met about 7,000 people a year. About 4,000 of those people are admitted involuntarily to the hospital on 72-hour holds. A small percentage of those progress to a 14-day hold. The majority of those people either continue their stay voluntarily in the hospital and are discharged or are discharged at the end of the 72-hour hold. That's 4,000 people minus a few who go to longer term care who -- which I'd like to refer to in a moment. SAUER: Absolutely. PLOPPER: Who are discharged into the community. And our charge is to attempt to connect them with continuing care after discharge. And we have some significant roadblocks to that. Out of great respect for the county programs, and these two gentlemen here. However we do have gaps in our services which contribute significantly to readmissions and a failed outpatient treatment. SAUER: One of the options for people is to be admitted to a locked long-term care facility. We spoke with Brian Miller, the chief psychiatrist with the outlying special treatment center about the change he's seen in the availability of beds. [ AUDIO RECORDING ] MILLER: The biggest change since I've been here, and I've been in San Diego since 1997, there were three long-term care facilities. But the intention is that a patient will be there for about six months, and the first week or two they're confined to the building, and thereafter they're able to go outside, progressively have more independence, and by the time they finish their stay, they're able to go on passes overnight with their families. And that's a way to progress people into the community. They weren't locked the whole time. But when I came to San Diego in 1997, there were three of those facilities. Currently there's one, and there's been a very deliberate effort to reduce those beds. My understanding is that it primarily has to do with cost. And so we have about 150 less long-term care beds in San Diego than we did. SAUER: So Alfredo, in terms of long-term beds how has the county made up for the 150 fewer beds for this population? AGUIRRE: Well, under the recovery model, and as our treatment models have improved, we've made a very strong effort to transition people out of those long-term care facilities into lower levels of care. Certainly we've made progress with the type of medications that are offered to individuals. And certainly doctor Miller pointed out the cost factor. Yes, we have to be resourceful, certainly, and unfortunately you may be aware of prop 63, mental health service act dollars, that does not provide for treatment in these types of facilities. So we're really working with whatever revenues we have, and we worked with some of our skilled nursing facilities, and we enhance care there. We looked at broadening our continuum to provide supports to people to be at a lower level of care and help transition them into the community. Some of the full-service partnerships have worked with people who have come out of those institutes for diseases that doctor Miller is talking about. So there are realities around beds and costs. Sometimes we do have to place out of county. Sometimes we have a -- a number of people in the state hospital. We work within our long-term care continuum that's offered. And we're looking at evaluating and advancing more of a long-term continuum. We realize we do need to add beds. Some individuals need that long-term care and maybe are not ready for the rehabilitation they just described. SAUER: What might you do to enhance that? AGUIRRE: We're looking at how to expand some beds for the hard to treat. There's individuals that actually don't even do well in those long-term care facilities because of their aggressive -- there are just issues, they're not real stable, they have concurring medical conditions or organic issues. So it gets in the way of treatment and rehabilitation. So we're looking at having intensive services, specialized beds to serve those individuals. SAUER: And Dr. Plopper, what impact does having fewer beds and long-term facilities factor into your ability or the county's ability with long-term care? PLOPPER: We frequently treat people for long periods of time who will have an average stay of seven days. But we'll treat people for several months as we're attempting to get them into long-term care facilities. We then if we cannot get them into the one facility in town are left with referring them or sending them to locked skill nursing facilitating out of county. There are only four in-county, and those are frequently full. So we send these folks out of county. These are people on conservatorship who are seriously and persistently mentally ill who then go to a facility which then provides only facility and custodial care. And we don't know what happens to them ultimately. And I believe it's unfair and not consistent with the recovery model to send a 28-year-old schizophrenic young woman to a locked skilled nursing facility out of her county, away from her family, and residing with older people with dementia. I don't think there's a solution. That's what we're living with today. And there are a large number of people, San Diego residents who live in these facilities currently because we have not had adequate resources in this community. SAUER: Okay. We wanted to get into conservatorship. Who's eligible for that and how does it work? AGUIRRE: There is a very lengthy, elaborate investigation of someone to determine if someone meets the criteria. SAUER: And time is limited. AGUIRRE: Usually the way it works, initially there's a 30-day temporary conservatorship, and then if individuals are not ready to be transitioned into the community, a consideration for a 1-year longer term conservatorship is evaluated and often granted. SAUER: We spoke with a woman, Shelly Kwik, her son had a dual-diagnosis, here's what she said happened when she looked into a conservatorship. KWIK: I called legal aid, and asked them if they could help me to get him under a conservatorship, and they said no because he was doing drugs. And they said that it's much more difficult if someone is doing drugs. SAUER: James, what options for conservatorship or other services do family members have in the county if the person they're trying to help has this dual-diagnosis? ROGERS: Well, throughout the county, there's been a large initiative called the comprehensive continuous care initiative, where all the facilities have equipped themselves with the goal of becoming dual-capable, which is to integrate mental health services with cooccurring substance abuse disorders. These used to be seen as two separate departments. Now many of the county programs are able to provide integrated services. SAUER: All right. We have another problem that we wanted to talk to, are and that's the families of the severely mentally ill face the cycle of incarceration. We spoke with a San Diego mother, Anita Fisher, about connecting her son to services when he was released from prison. FISHER: Even though he is in the psychiatric area of the prison when he's there, so it's of course then validated that he obviously lives with a mental illness, but upon release, there is no connection to services. There is no connection that this person needs -- I refer to it as a warm handoff, where someone does pick him up and take him and connect him to the services that he might need. Because my son has a choice in if he wants us to pick him up. We were ready and available to do that. But if he doesn't let us know exactly what time he's leaving, we don't know. We can't. So we're just here now with a missing person. SAUER: So Alfredo, without knowing when her son is released, what can someone like Anita do to get him help? AGUIRRE: There's two categories of individuals who are leaving state prison. One, they're released on parole, and there are some state-operated parole outpatient clinics. With state funding for these kinds of programs being reduced dramatically, the services and resources available for people who need this kind of outpatient care, not just the basic medications but also case management, has been reduced. So they often call us, and we try to do our best to compliment what they can't provide in terms of those individuals who are on parole. The second category of people who through the governor's realignment initiative a couple years ago, now you're seeing individuals who are released earlier into county jail. Then you have the ones that are released to the community called the post-release offender population, also under what's called AB-109. And they come under the jurisdiction of probation. The good thing there is a lot more services are offered to those individuals. We offer all our levels of care, both substance abuse services as well as mentally health service, depending on the need, work closely with probation. They do a thorough assessment, and they're referred out. So it really depends on the category of -- under what jurisdiction is that individual referred to. SAUER: Are those services voluntary or involuntary? AGUIRRE: Well, I would say there is some leverage. I would say they're court probation-ordered. There are some ability to do sanctions, particularly with probation. There are sanctions available if they do not go to their assessment appointment and they don't comply with treatment. So there is in essence a law enforcement black robe effect that does make a difference for those individuals. SAUER: And the county's health and human services making recommendations to the Board of Supervisors, they're going to vote next week how best to improve the safety net here. What are the recommendations? AGUIRRE: The recommendations -- our in-home outreach team, which is our alternative to what's provided under Laura's law. We're intending to expand in three region, north coastal, east, and central. We are expanding to north inland, south county, and north central areas of the county. The other recommendation of course is to accept the report on the study you referred to. And then the third is to take real clear steps to looking at what it would take to implement Laura's law, identify the revenues, look at perhaps some legislative remedies to strengthen the law. SAUER: And Dr. Plopper, your last word on the recommendations? PLOPPER: Well, I think that the IHOT program is a great program, but I think it's a different population we're talking about. There are a set of people in this community, probably about 1,000 who have serious mental illnesses, and aren't aware they have those illnesses, or unwilling to accept those illnesses, and can be a danger to themselves or others. Assisted outpatient treatment through Laura's law allows a remedy, and allows us to monitor and treat those individuals. SAUER: All right. Thank you very much for being here today.

REVIEW OF SERVICES FOR INDIVIDUALS WITH SERIOUS MENTAL ILLNESS WHO ARE RESISTANT TO TREATMENT
San Diego County Health and Human Services report to the San Diego County Board of Supervisors REVIEW OF SERVICES FOR INDIVIDUALS WITH SERIOUS MENTAL ILLNESS WHO ARE RESISTANT TO TREATMENT.
To view PDF files, download Acrobat Reader.

In March, the Board of Supervisors tasked County health administrators with reviewing the system of care for the seriously mentally ill. Health administrators had 90 days to compare the County's current voluntary services to Laura's Law, a mandatory, court-ordered treatment program.

County health administrators released a report earlier this month. They recommended the Board of Supervisors expand the county's voluntary In-Home Outreach Team, or IHOT, program, and consider a path for adopting Laura's Law.

County Mental Health Director, Alfredo Aguirre believes it's the County's responsibility to provide a "safety net" service system for people with serious and persistent mental illness.

But he says there are barriers to adopting Laura's Law here. The county doesn't have the money to pay for the program, and funds from a state mental health law cannot be used for it. There is a bill making its way through the state legislature that would clarify funding restrictions, but it won't be voted on until September.

Voluntary Versus Mandatory Treatment

Some mental health advocates are critical of the County because they say people who need mental health services but refuse treatment are falling through holes in the public "safety net" that's intended to help them because the County does not have a court-ordered treatment program like Laura's Law.

Aguirre said more than 41,000 adults get mental health services from the county. Of those, he said 1,100 of the highest risk people participate in the County's "assertive community treatment" programs called full service partnerships.

James "Diego" Rogers runs one of these programs for the Community Research Foundation. He said they've been successful in getting people who are resistant to treatment into the program.

"We’ve been able to see results where through the aggressive outreach, see individuals go from being homeless one day to have an apartment or housing the following day," he said. "The mental health services are delivered in the community where the client is residing or even out on the streets – bringing the psychiatrist to them, bringing the clinicians to them."

But gaps in services have contributed to repeat hospitalizations and a failure in outpatient treatment, said Dr. Michael Plopper, chief medical officer for Sharp Hospital's Behavioral Health Services.

He said about 4,000 people are admitted involuntarily to Sharp hospitals in San Diego County each year for 72-hour psychiatric holds.

"Our charge is to connect them with continuing care after discharge and we have some significant roadblocks to that," he said.

One option is to admit people to an Institution for Mental Disease. These are locked facilities that provide long-term psychiatric care. Patients stay in IMDs for about six months and progressively become more independent as they integrate back into the community.

But there is only one in San Diego County -- the Alpine Special Treatment Center.

Brian Miller is the center's chief psychiatrist, and he said when he began practicing psychiatry here in 1997, San Diego had three such centers.

"There’s been a very deliberate effort to reduce those beds," Miller said. "My understanding is that primarily has to do with cost and so we have about 150 less long term care beds in San Diego than we did.”

Aguirre said the County focused its efforts away from using long-term care facilities and into lower levels of care like the full service partnerships for several reasons. For one, the county could not use state funding for the longer-term care, and medication improvements have made that kind of care less necessary.

But Plopper said the need for long-term care persists. People often spend several months in Sharp's psychiatric hospitals waiting to be transferred into a long-term care facility.

And because San Diego has only one facility, patients are sometimes sent outside the county, which creates its own set of complications.

"I believe it’s not consistent with the recovery model to send a 28-year-old schizophrenic young woman to a locked skilled-nursing facility out of her county, away from her family and residing with older people with dementia," he said. "I just don’t think that’s a solution, that’s what we’re living with today."

Conservatorship

One option for getting a severely mentally ill person into a stable living situation is appoint a conservator -- someone who is allowed to make decisions on their behalf. Even that can be tricky, though.

Shelly Kwik, said her son Evan had a dual diagnosis — mental illness and addictive disorder — and because of that it was too hard to get a conservatorship because doctors could not necessarily diagnose the whether drugs or mental illness were the root of his problems.

“I called legal aid and asked them if they could help me get him under a conservatorship and they said 'no' because he was doing drugs and they said it’s much more difficult if someone is doing drugs,” she said.

James Rogers, who runs the full service partnership, said mental health and substance abuse disorders used to be treated separately but that is changing as clinics try to adopt comprehensive approaches to treating people with mental illness and addictive disorders.

The Revolving Door To Prison

Another problem that families of the severely mentally ill face is the cycle of incarceration.

Anita Fisher said her son Pharoh Degree, who is diagnosed schizophrenic, has been missing since he was released from Donovan State Prison just a few weeks ago.

She said her son was held in the psychiatric area of the prison but when he was released, there were no resources for him.

"There is no connection to services, there is no connection that this person needs. I refer to it as a warm hand off, where someone does pick him up and does take him and connect him to the services that he might need," Fisher said. "'Because my son has a choice in if he wants us to pick him up. We were ready and available to do that. But if he doesn’t let us know exactly what time he’s leaving, we don’t know. We can’t so we’re just here now with a missing person."

Alfredo Aguirre, the county's mental health director, said funding cuts related to prison realignment have resulted in reductions in services at state parole outpatient clinics.

"The resources available for these kinds of people who need this kind of outpatient care, not just the basic medications but also case management has been reduced," he said.

He said the County has tried to bridge the gap left by cuts to state parole programs.

"They often call us and we try to do our best to complement what they can’t provide," Aguirre said.

He said under realignment, the state's program to transfer supervision of people convicted of non-violent crimes to the counties, more people are falling under local jurisdiction of the County's Probation Department.

"The good thing there is a lot more services are offered to those individuals. We offer all our levels of care, both substance abuse services as well as mental health services depending on the need," he said.

He said people released from County jails can be court-ordered into treatment.

Next week Aguirre will make recommendations to County Supervisors on how best to improve the "safety net" for the severely mentally ill.

He'll recommend the county expand its In-Home Outreach Team, the County's voluntary treatment alternative to Laura's Law, the mandatory program. He'll also recommend a path to possible adoption of Laura's Law.

Plopper said he thinks the in-home program is great but isn't enough to reach mentally ill people who resist treatment.

"There are a set of people in this community, probably about 1,000 who have serious mental illnesses, and aren't aware they have those illnesses, or unwilling to accept those illnesses, and can be a danger to themselves or others," he said. "Assisted outpatient treatment through Laura's Law allows a remedy, and allows us to monitor and treat those individuals."

On July 30, San Diego County's Board of Supervisors will vote to accept the agency recommendations, or not.

This story was produced with support from the USC Annenberg/California Endowment Health Journalism fellowship.