As people in crisis flood San Diego County hospitals, more patients and families are confronting a shortage of longer-term care.
The countywide deficit of so-called step-down care and housing options for psychiatric patients being discharged from local hospitals has led to long, expensive waits in hospitals that burden patients, families and hospital staff.
Psychiatric patients, just like those with physical health conditions, must continue their recoveries outside of the hospital. Patients often need a supportive environment that may come with temporary or long-term housing, counseling and assistance with medication to help them stabilize and ideally thrive after they leave the hospital.
County data reveals the number of adult behavioral health patients with Medi-Cal insurance or without insurance who have been stuck waiting in hospital beds for post-hospital care has more than quadrupled over the last decade – and the number of the days they are waiting has also surged.
During the same period, county data shows the number of psychiatric patients who were hospitalized and discharged spiked 59 percent.
“The biggest challenge is there’s nowhere to go,” said Jerry Gold, Scripps Health’s behavioral health administrator.
County behavioral health officials, county supervisors and advocates agree that more post-hospital options are needed to clear waits, and the county has recently funded more beds for patients who need weeks or months of additional care.
Yet patients, families and hospital social workers still face a complex maze of options and waits. There’s not a comprehensive, public inventory of services and housing with open slots – and even county and hospital officials can differ on the definitions and standards for various types of after-care, only adding to the confusion.
County Supervisor Nathan Fletcher has called a meeting of local health care leaders later this month to try to get consensus on various types of post-hospital care.
“We know that we don’t have enough of them,” Fletcher said. “There’s not agreement on what they all actually are.”
Fletcher believes settled definitions will help decision-makers focus on which after-care options should be bolstered.
A broader housing crisis has also exacerbated gaps, fueling the shuttering of board-and-care homes in San Diego and across the state that have long been considered crucial housing options for people with serious mental illnesses. State reimbursement rates for the facilities haven’t kept up with staff and housing costs, making the longtime business model infeasible for many owners.
As demand for post-hospital care and housing has boomed, a 2-1-1 San Diego analysis reveals the region has lost at least 206 board-and-care beds since 2012. The social service resource line reports it makes an average of 80 referrals a month for just 828 listed board-and-care slots.
San Diego County has also been slower than other big metros in the nation to build permanent supportive housing projects that can welcome formerly homeless people who have been treated for serious mental illnesses. An analysis by the San Francisco Controller’s Office recently found San Diego had the lowest number of supportive housing units per capita of the 18 large metros reviewed despite having the nation’s fourth-largest homeless population.
The limited options have contributed to a clogged system.
“The resources we have here are at full capacity,” said Rhaelynne Scherr, who leads a team of 15 social workers at Alvarado Parkway Institute who connect patients at the La Mesa psychiatric hospital with longer-term care or housing.
As of last week, Scherr said, 25 of the hospital’s 66 patients were awaiting longer-term care.
Alvarado Parkway Institute took a proactive step and opened the Jackson House, its own 15-bed step-down facility, in September 2017 in response to frequent waits for openings in county-funded crisis homes that typically provide about two weeks of post-hospital support.
But crisis homes are just one of several types of post-hospital care for patients.
Some patients require months or even years of care at mental health rehabilitation facilities such as the Alpine Special Treatment Center or at skilled nursing facilities such as the Lakeside Special Care Center.
While the county has funded dozens more mental health rehabilitation beds, county data reveals patients waited an average of 61 days last year.
Advocates and hospital officials, including Scherr, said the waits can be frustrating for high-need patients already grappling with a hospital stay.
“They see [other] people come and go, and they wonder, ‘Why can’t that be me?’” Scherr said.
For homeless patients, county and hospital officials sometimes look to so-called recuperative care facilities that can accommodate homeless San Diegans for a few weeks as they recover from hospital stays.
A new state law mandating that hospitals establish plans for discharging homeless patients has put a spotlight on the dearth of resources for homeless patients. San Diego County has only a few dozen recuperative care beds, but more are on the way.
County Supervisor Kristin Gaspar this summer successfully urged the board to allocate millions of dollars to help Escondido-based Interfaith Community Services expand its 32-bed recuperative care program. Fletcher and officials with nonprofit Family Health Centers of San Diego, which operates health clinics across the region, separately told Voice of San Diego they are continuing to explore options to add recuperative care beds in the city of San Diego too.
But homeless patients or those whose housing situation is unstable coming out of recuperative care homes – and leaving the hospital – often need more permanent homes.
While San Diego and other parts of the state have seen declines in board-and-care facilities, Melanie Briones of San Diego’s county-funded Independent Living Association said there has been a steady rise in independent living homes accepting people with behavioral health conditions.
Briones said the organization now has 85 member homes equipped to provide less intensive aid to mental health patients than board-and-care homes. The association has aimed to encourage best practices for independent living facilities, which are now unregulated, and has created a directory of its homes.
Independent living homes – and even permanent supportive housing – can’t serve all patients.
Some patients need a higher level of care that comes with more supervision and assistance with medications than independent living or supportive housing options are equipped to provide. They may also need substance abuse treatment or residential programs that can treat both their mental illness and their addiction.
Briones and Cathryn Nacario, CEO of the National Alliance on Mental Illness San Diego, said patients sometimes end up in independent living homes when other programs are unavailable.
“They’re getting some people who really aren’t ready for that level of care,” said Nacario, whose organization is considering its own investments in independent living programs.
To try to combat that problem and statewide losses of board-and-care homes, Los Angeles-area Assemblyman Richard Bloom is pushing AB 1766, which would require the state to track how many board-and-care homes take in people with serious mental illnesses to help decision-makers better gauge what’s available – and what’s needed.
“We just see this need for a continuum that isn’t there. That is a huge problem for the state,” said Adriana Ruelas of the Steinberg Institute, a mental health lobbying group founded by Sacramento Mayor Darrell Steinberg. “We need to know what we have available. We need to know how we can incentivize these facilities to stay open.”
County officials hope to deliver more options soon. San Diego is poised to see a rush of bond money from the state’s No Place Like Home initiative to build housing for homeless people with serious mental illnesses. The county is also searching for a provider to open up a dozen board-and-care beds for elderly San Diegans leaving psychiatric hospitals.
County behavioral health officials Luke Bergmann and Michael Krelstein said they are also focused on making various parts of the mental-health system work together more seamlessly for patients and families – from hospitals to step-down care.
Bergmann said the county is exploring ways to encourage hospitals to help the region invest in data-sharing and perhaps different care models that might better address patients’ needs and experiences. He noted that hospitals lose significant cash when patients are stuck waiting in beds.
“I think we can see opportunities to incentivize investment in collaboratively building the kind of an aggregate, care-coordinating aggregate that would be to the fiscal advantage of hospitals,” Bergmann said.
Bergmann declined to elaborate on how that might look.
For now, navigating the various types of homes – and finding post-hospital options that seem like a good fit can be overwhelming, even for seemingly well-equipped patients and families.
Lynette and Gary Cederquist of Sorrento Valley faced that challenge last September as they prepared for their 18-year-old son Eric to be released after a three-week stay in Palomar Medical Center’s behavioral health unit.
The couple decided Eric, who was grappling with psychosis, was not ready to return home. Lynette Cederquist, a physician, sprang into action after encountering a series of different social workers who she felt weren’t able to focus on her son’s case.
“I was desperately calling to find out where he could go live after he left the hospital,” she said.
One residential treatment facility had a two-to-three month wait. Another would cost up to $15,000 to $20,000 a month. Some programs wouldn’t take insurance.
Immediately after his release, Eric Cederquist ended up at a residential program in Vista that didn’t work out and soon after, at an independent living home near San Diego State University. Eric’s mental illness ultimately took his life. He died by suicide in January.
Derryl Acosta, a spokesman for Palomar Health, said the hospital social workers typically assist in placing patients in aftercare about 80 percent of time and communicate with patients daily about post-discharge plans. He declined to comment on the Cederquist family’s specific experience.
But Acosta said Palomar’s social workers, who are trained to help patients navigate next steps, experience some of the same challenges the Cederquists did as they tried to navigate a complicated step-down system with few openings.
“They have to make the calls to each one of those places and see if there is an opening,” Acosta said.