A shortage of long-term care options for behavioral health patients that has for years fueled a clogged care system became an even bigger problem during the pandemic.
The COVID-19 crisis that limited healthcare access further exposed San Diego County’s deficit of psychiatric step-down care and housing that had already led to long waits in hospital beds and delays for others seeking hospital care.
County data obtained by Voice of San Diego reveals the number of days that adult behavioral health patients with Medi-Cal insurance spent waiting in hospital beds for post-hospital care surged 48 percent from fiscal year 2020 to 2021.
Patients also collectively spent more than 19,000 days waiting in hospital beds regionwide after doctors decided they were ready to be discharged to a lower level of care during the fiscal year that ended this June. That total is 40 percent higher than the waits reported two years ago.
Those waits have wreaked havoc on the rest of the system and an upcoming state mandate to provide and compel treatment through the state’s new CARE Court initiative by October 2023 will put more pressure on the region’s limited options. If the county can’t deliver civil court-ordered care for CARE Court participants, it could face fines of up to $1,000 a day.
Steve Koh, chief of general psychiatry at UC San Diego Health, said he fears more patients will be stuck waiting in emergency rooms absent new long-term options.
“Where am I supposed to send them?” he said.
County officials who have in recent years focused most of their investments in crisis services rather than back-end resources expected to be crucial landing places for CARE Court participants are pledging action. They plan to soon unveil an analysis of the region’s need for longer-term care options, and an expansion strategy.
County supervisors also recently created a training fund to address the region’s shortage of behavioral health workers. County Board of Supervisors Chair Nathan Fletcher argues the shortage is hampering efforts to expand services.
Fletcher and Mayor Todd Gloria, both advocates of CARE Court reforms, note that Gov. Gavin Newsom has devoted significant funding to help counties expand their behavioral health systems, including $1.5 billion for so-called bridge housing.
Clearing existing clogs in the behavioral health system – and serving CARE Court participants – will likely rest on the county’s ability to deliver new beds.
Historically, there were three phases of medical care for patients in psychiatric distress: the emergency room, an inpatient hospital bed where patients could stabilize and post-hospital care for specialized treatment.
A shortfall in the latter category has caused a systemwide backup.
Exhibit A: On a single day in late August, 10 of the 36 inpatient behavioral health beds at Scripps Mercy Hospital in Hillcrest were filled with patients waiting to move to another level of care, meaning more than a quarter of Scripps beds weren’t available to patients in crisis.
The county has funded so-called crisis stabilization units the past few years so fewer psychiatric patients enter local ERs and then inpatient beds, but patients still need somewhere to go after they leave local hospitals.
Those hospital patients awaiting beds at long-term care facilities waited an average of 48 days between July 2021 and April, according to county data obtained by Voice.
Christiana Paul, a vice president at Sharp Mesa Vista Hospital, said waits challenge both patients and hospital staff.
“It just really sticks this person with us for these long periods of times where this person has cycles of great improvement, and then because of the length of the time in the hospital, (they) may even regress, which is very demoralizing for the patient and the staff,” Paul said.
The San Diego County Psychiatric Hospital has been hit with long waits too. The county reports average wait times to move patients from the county hospital to a state hospital surged to an average of about three years from July 2020 through June 2021. That’s up from about five months in the 2019 fiscal year.
“Sometimes we have to opt for a different level of care, or they wait in the hospital until we can place them,” said Annie Vizcarra, social services manager at Alvarado Parkway Institute.
Aaron Mellon, a trained peer counselor with bipolar disorder who grappled with homelessness on and off for more than a decade, estimated he has watched a few dozen friends stabilize in hospitals only to be forced back onto the street.
“For a lot of people, it’s a never-ending loop,” Mellon said.
Clairemont resident Anastasia’s 26-year-old son has bipolar disorder with psychotic features and has been hospitalized several times since 2020. She said he struggled at independent living facilities even while enrolled in an intensive treatment program.
Anastasia said she was repeatedly told there were no openings in board-and-care homes, which typically provide residents with assistance with medication and greater oversight. The homes long considered crucial housing options for people with serious mental illnesses are a shrinking resource statewide.
After one five-day hospital stay for an infection and another five days at nursing facility this spring, Anastasia and her son’s case managers agreed he shouldn’t return to his independent living home, but there was no space in a board-and-care home.
He moved into her Clairemont home, forcing Anastasia to get permission to work from home.
Carol, a retired teacher who lives in Tierrasanta, said her 41-year-daughter diagnosed with schizophrenia has been kicked out of more than 15 independent living homes in the last 13 years. Multiple facility managers have said she belongs in a board-and-care facility.
“She needs a higher level of care,” Carol said.
They haven’t found it.
Indeed, 2-1-1 San Diego reported the region lost nearly 400 board-and-care beds over the last decade.
Skilled nursing facilities fit for behavioral health patients with medical issues are also scarce.
Psychiatrists say the sicker the patient, the more difficult it is to find a place for them.
Earlier this year, the state awarded the county $12.4 million for a 12-bed psychiatric unit in its Edgemoor Skilled Nursing Facility to allow residents to get psychiatric care without transferring.
Moving into mental health rehabilitation facilities means long waits, too.
Local hospital systems said waits rose significantly during the pandemic but are leveling off at a one-to-three month wait.
The situation could have been worse. Before the pandemic, the county funded dozens more mental health rehabilitation beds.
The region has also added nearly 2,300 permanent supportive housing slots for formerly homeless people who are considered particularly vulnerable – including people with serious mental illnesses – since early 2019. But those additions haven’t dramatically reduced waits in hospitals and many behavioral health patients require more support than those facilities offer.
“The fact of the matter is we just need more post-acute care,” said Dimitrios Alexiou, CEO of the Hospital Association of San Diego and Imperial Counties.
Nadia Privara Brahms of the county’s behavioral health services department recently told an advisory board the county plans to boost step-down care and will share its needs at a Sept. 27 meeting.
“Instead of being stuck in more acute care or not being able to get care at all because those levels of care or types of beds that they need don’t exist, the goal is to continue to build out capacity much of which is in the lower, less restrictive areas of care to make sure clients get connected and then they are able to get care long-term,” Privara Brahms said.