County Under Pressure to Deliver More Behavioral Health Beds

This story is part of our It’s Gonna Blow reporting series. Read more stories here.

It’s long been a foregone conclusion among those trying to help San Diegans with behavioral health challenges: San Diego County doesn’t have enough beds for all who desperately need them. 

Now with the backdrop of new state mandates expected to increase demand, an addiction epidemic and a March state bond measure aiming to fund more beds, the pressure is on the county to deliver. 

Exactly how many beds the region needs remains unclear. The county has yet to share overarching projections but suggested it needs hundreds of new community-based beds for mental health patients alone. That was before factoring in the latest reforms. 

What is clear is that the county doesn’t have enough beds to meet the existing demand. 

The local hospital association reports that behavioral health patients collectively spent more than 17,500 days waiting in hospitals regionwide after doctors decided they were ready to be discharged to a lower level of care last fiscal year – a figure that speaks to the lack of readily available step-down options for these patients.  

And for people with Medi-Cal insurance who are struggling with addiction, getting immediate access to one of the county’s 78 contracted detox beds is like winning the lottery. Medi-Cal patients can also wait weeks for longer-term residential treatment. 

In 2024, state reforms will force the county to confront these gaps and others. Addressing them won’t be easy, even if the $6.4 billion bond measure meant to bolster behavioral health infrastructure statewide passes.  

Exhibit A: Two of the county’s major substance use treatment providers have spent years trying to supply more detox beds without success. One even has $12 million in pledged local government support to make it happen.  

What’s Behind the Building Pressure

San Diego County’s behavioral system has been clogged for years. After the Affordable Care Act went into effect in 2014, more patients in crisis ended up in local ERs. In more recent years, these patients have sometimes waited days to move into an inpatient bed. Once they’re deemed stable enough to leave the hospital, still vulnerable patients now often spend even more time waiting for a place where they can continue to receive support. San Diego and communities statewide have faced soaring homelessness and addiction crises that have put more pressure on those service systems too. 

Gov. Gavin Newsom, San Diego Mayor Todd Gloria and other lawmakers have in recent years been determined to institute reforms they think could turn the tide.  

Enter the big reforms: In October, San Diego County became one of the first in the state to implement a new court system that compels people with psychotic illnesses into treatment. While the county has emphasized that the initiative is focused on a narrow group of people with serious mental illnesses, it estimated it’ll need 872 housing options – including supportive housing, licensed care beds and shelter – for CARE Court participants alone.  

The county’s behavioral health services director has said SB 43, a state conservatorship reform bill Newsom signed this fall, will bring even more pressure. 

The county considers the associated burden so daunting that supervisors postponed implementation of the state law expanding conservatorships to include people with severe substance use disorders to allow time to bolster treatment options and minimize the impact on local hospital emergency rooms.  

Newsom, meanwhile, has said he’s talking with state lawmakers about ways to lay down the hammer on counties that don’t step up following the news that dozens of counties statewide are also holding off. He argues the state has “cleared the decks” by teeing up more funding for services and that it’s time for counties to act.  

“I’m not interested in sort of institutional failure or apathy in this space anymore,” Newsom said. 

While Newsom has deployed state money to bolster behavioral health offerings and championed the state ballot measure, San Diego County officials have emphasized that the conservatorship reform bill itself didn’t supply new cash to tackle the needs it’ll create. They have also said they need time to ramp up resources – read: new beds, services and connection options – to ensure the reform doesn’t simply result in people cycling through ERs without being linked with treatment. 

“The Board of Supervisors has elected to plan and build operational elements that will prevent the revolving door at the emergency department for people with substance use disorder from just spinning faster,” county spokesman Tim McClain wrote in a statement. “Otherwise, people with substance use disorders brought involuntarily to emergency departments would likely suffer poor outcomes, and people needing emergency care who don’t have substance use disorders will likely have their care compromised as well.” 

County officials have already decided to pursue locked substance use treatment beds for patients who are conserved that are now nonexistent, places other than hospital ERs that can take in people deemed gravely disabled and increased linkages between ERs and treatment programs in the community. 

Like Newsom, Gloria and Supervisor Terra Lawson-Remer have expressed frustration with a county board majority’s call to not move forward as it works to build out those resources.  

The two San Diego Democrats have said they believes the county can’t wait for additional funds and infrastructure to materialize while San Diegans struggling with addiction or mental health crises languish.  

Lawson-Remer, who voted against postponing implementation, argued in a recent Union-Tribune op-ed that the county should treat the situation with the same urgency as it has public health crises and disasters. 

“Implementing SB 43 was not the time to pull back — we should have continued to press ahead by using this tool to help as many people as possible,” Lawson-Remer wrote. “We must continue to make wise investments that increase our region’s capacity to deliver mental health and addiction treatment.” 

What’s Already in Play

County officials are pledging to meet with stakeholders to hash out how to tackle new demands tied to SB 43. They are set to update supervisors on those discussions and the time they’ll need to implement conservatorship expansion in late March.  

Lawson-Remer has also said she plans to this month formally propose county investments in step-down beds for homeless patients to support SB 43 implementation. 

On the same day Lawson-Remer’s colleagues voted to delay implementation of SB 43, the San Diego City Council unanimously declared a behavioral health bed crisis.  

City Councilman Raul Campillo, who introduced the declaration, said it was meant to bolster the city’s work with other government entities including the county and to direct city staff work on zoning reforms to help address the bed shortage.  

The city’s draft zoning code updates for 2024 now include a plan to streamline the permitting process for residential behavioral health facilities. 

A Window Into the Challenge

Two substance use treatment providers’ years-long struggles to open new facilities highlight the hurdles the county will face as it tries to add more beds absent significant changes. 

McAlister Institute, the county’s largest substance use treatment provider, has for the past few years been on the hunt for a site. The nonprofit has deemed dozens of properties unworkable for a laundry list of reasons despite its determination to serve more people in need and $12 million in pledged funds from the county and city it had expected would ease the process. 

Marisa Varond, the nonprofit’s executive director, said late last month that the McAlister Institute was exploring property No. 51 in the Midway District – and hoping for the best. 

Jerry Shirey of Campo-based San Diego Freedom Ranch, another county contractor, has the opposite problem. He found a property in unincorporated El Cajon that he believes could serve as a recovery campus with dozens of new detox and residential treatment beds by early 2025 – and multiple additional services within three years. He needs the money to make it happen. 

Shirey said the county’s behavioral health director told him during a December meeting that the county is unable to provide immediate funding for the project despite its interest in adding more detox beds.  Shirey is now trying to raise millions of dollars.  

“We are beating down doors trying to find the money,” Shirey said. “At the end of the day, my view is the county needs the beds.” 

McClain said the county is trying to deliver more detox beds too including via “additional infrastructural investments that have been long in planning” and intends to continue contracting with providers through its competitive procurement processes. He didn’t elaborate on its specific plans.