Treatment Beds Still Elusive as County Enacts Conservatorship Expansion

On Jan. 1, the county will enact a state conservatorship expansion law that local hospitals, treatment providers and county officials declared last year they weren’t ready to handle. 

A year after county supervisors voted to postpone implementation of the law aiming to make it easier to force people with severe substance use disorders into treatment, the county has taken steps to try to minimize the impact on hospitals that feared a flood of emergency room patients on initial involuntary holds of up to 72 hours. 

What the county has yet to deliver before moving forward with SB 43 is additional residential treatment and detox beds in a system now unable to meet existing demand for those who voluntarily seek care – at least for now. It’ll start the new year with about 100 fewer contracted beds for Medi-Cal patients than it had when supervisors voted to postpone implementation of the law broadening eligibility for both conservatorships and shorter-term holds following a major treatment provider’s forced closure. Plans are in the works to open dozens of new beds in early 2025 and beyond with the help of competitive state bond funds. That new capacity won’t be available before the county enacts SB 43. 

Yet county Behavioral Health Services Director Luke Bergmann said he’s not panicking. 

Bergmann says the county’s controversial decision to postpone implementation of the new law last year – frustrating leaders including Gov. Gavin Newsom, San Diego Mayor Todd Gloria and county Vice Chair Terra Lawson-Remer – provided a runway.  

“The work we have done in preparing and becoming ready is profound and puts us in a vastly different position than we would have been a year ago,” Bergmann said. 

Bergmann said law enforcement training and conversations that the county has convened since last year now suggest police countywide will not immediately pursue dramatically more short-term holds.  

The county estimates what would amount to at least a 10 percent spike in short-term holds tied to the new law in its first year based on feedback from police and other information it’s gathered. 

Another new state policy is expected to put even more strain on the existing system. 

Recently voter-approved criminal justice reform measure Proposition 36, which increases penalties for some low-level crimes and options to force offenders into treatment, has spurred questions statewide about the treatment system’s capacity to respond. 

Bergmann told Voice of San Diego in early December that while he does expect the measure will impact the local treatment system, the county had yet to project how it would escalate demand. 

Jerry Shirey, who for years led San Diego Freedom Ranch’s now 54-bed facility in Campo, predicts the two changes will collectively lead to at least a 25 percent spike. 

“Everywhere the consensus I hear is we’re not sure how we’re gonna handle it,” Shirey said. “We have shortages.”  

After all, Shirey said, San Diegans with Medi-Cal insurance seeking detox or longer-term residential treatment programs now often wait weeks for a bed. 

Gloria, who last year tried to persuade the county to implement SB 43 this past January, said he’s disappointed that the county hasn’t made more progress increasing treatment options since then. 

“After waiting a year, the expectation would be that year was gonna result in certainly more than no beds,” Gloria said. 

Many San Diego advocates, hospitals and treatment providers remain concerned and uncertain about what will happen next with SB 43 alone – and where patients will go.  

The expansion law covers people whose addiction and mental health challenges threaten their safety and access to necessities like medical care, meaning those picked up by police are likely to have other health issues. That also means they may not be ideal candidates for existing treatment programs that aren’t set up to serve people with even common health challenges that require extra aid and oversight. 

Because Bergmann and others expect holds for most patients to be dropped by hospital staff after they sober up, SB 43 won’t necessarily result in more of these patients receiving continued addiction treatment unless hospitals and other providers can swiftly connect them with treatment that has often been elusive for people with Medi-Cal insurance.  

One city’s first year with SB 43 highlights the need for more options. 

The San Francisco Chronicle reported that the Bay Area city has seen a 30 percent spike in people seeking residential treatment and a 29 percent increase in temporary conservatorships since that city implemented SB 43 in January. Absent an ample increase in options for these patients, deputy public conservators in San Francisco told the newspaper that patients often still end up back on the street and continue to cycle through ERs and jails. 

Bergmann says he expects San Diego to have a different experience, largely due to conversations the county has had with local law enforcement agencies including the San Diego Police Department. 

“I feel confident that we will have a measured approach to the application of holds,” Bergmann said. 

In the months before implementing SB 43, the county has used $15 million in federal American Rescue Act Plan funds to try to stem the impacts of what is still an expected increase in holds. 

The county is directing officers to take more patients picked up on so-called 5150 holds to crisis stabilization units that can keep them for up to 24 hours rather than hospitals following regulatory and contract changes allowing crisis units to care for patients with substance use disorders. The county has also updated a slew of other contracts to allow hospitals and other providers to accommodate and receive reimbursements to treat patients with addiction issues. One of those contracts is with Alvarado Parkway Institute, which under an expanded county contract can take in patients who need addiction treatment services in a hospital for holds extending beyond 72 hours. 

The county also plans to pursue contracts early next year with existing recuperative care programs designed to accommodate homeless patients who lack a safe place to recover that have traditionally focused on people with physical health ailments to try to increase options. 

Bergmann said he expects the recuperative programs – and additional respite beds the county plans to eventually open at a National City facility – to ease patients’ transition from hospitals into treatment options throughout the community. 

The county and some hospitals are also rolling out initiatives and hiring staff to help patients connect with services including residential, outpatient and medication-assisted treatment after landing in ERs. Those efforts themselves won’t translate into open beds for those who need them. 

But Bergmann and county board Chair Nora Vargas emphasized increased county investments in outpatient treatment options and homes where people in recovery can stay while enrolled in treatment in recent years, an option they said can help some of these patients. 

“While I recognize the ongoing need for more residential treatment options, we’ve significantly increased our capacity for outpatient substance use disorder services by more than 10 percent over the past few years,” Vargas wrote in a statement. “Outpatient care, combined with sober living (homes), is highly effective for many individuals and remains the most sustainable form of treatment.” 

Bergmann said this pairing could be ideal for many Proposition 36 offenders too. 

Those options won’t work for San Diegans struggling with more complex addiction and other health challenges, particularly if they are placed on longer-term holds or conservatorships.  

For now, Bergmann confirmed the region doesn’t have any locked treatment options for people with substance use disorders. Following state regulatory changes in recent months, he said the county can now work on establishing options. He’s not expecting the region will need a high volume of them. 

Bergmann acknowledged the county also still needs more unlocked residential treatment capacity – and required it even without new pressures tied to state policies. 

The largest source of funding for new treatment options won’t supply a rapid onslaught of new beds. 

The county and more than two dozen providers are vying for state bond funding unleashed by state Proposition 1 that could bolster treatment offerings in a few years.  

On the county’s wants list: State bond funds to support a 72-to-96-bed treatment center that includes detox services and post-hospital care for unstably housed residents at a long-shuttered treatment facility  in National City the county hopes to open in early 2026. 

A handful of providers are also determined to collectively open about 90 new detox beds sometime early next year to help the county exceed its current roster of just 78 beds for Medi-Cal patients. They can’t promise exactly when they’ll open. They must wait on sign offs and support from the county and others before they can proceed. 

Interfaith Community Services expects to add 21 more county-contracted detox beds in Escondido by February but awaits key city permit approvals while Father Joe’s Villages is still working out plans to open a 45-bed program in East Village early next year. Genesis Recovery, meanwhile, thought it could open 24 beds in Dulzura as soon as January – if it got a county contract that is yet to be awarded. The county now expects to make an announcement early next year. 

The county kickstarted that bidding process this fall to replace 101 now-shuttered longer-term residential beds at Veterans Village of San Diego, which was forced by the state to stop providing substance use treatment earlier this year, and to allow competition for another existing residential treatment contact. The county could award contracts to supply up to 189 beds but for now has 100 fewer residential treatment beds than it did just months ago. 

Advocates and families of people with behavioral health challenges are bracing for what’s next. Some wish the county had moved forward with the new law this year and criticize the county for putting off a way to help vulnerable residents. 

Linda Mimms of the Schizophrenia & Psychosis Action Alliance was among those who wanted the county to move forward with SB 43 sooner. She’s trying to stay hopeful going into 2025. 

“I don’t know what’s going to happen but I’m very, very happy that it’s going to go into effect,” Mimms said. 

Others fear implementing SB 43 this January could do more harm than good absent more access to treatment options, including voluntary ones that patients can seek on their own. 

Cathryn Nacario, CEO of the National Alliance on Mental Illness San Diego, attended county SB 43 stakeholder meetings earlier this year and wishes the county would take another year prepare. The legislation allowed counties to hold off until 2026 though Newsom and others have criticized counties that opted to postpone implementation. 

“I think we’d be more successful if we had the opportunity to wait another year,” Nacario said. “These are fundamental changes to the system that have to take place and 12 months is too short to provide the quality care that we need – and just to get the contracts in place.” 

Mike Phillips of Jewish Family Service of San Diego, whose organization has led county trainings with law enforcement and other stakeholders and advocates for behavioral health patients, said he believes San Diego County has prepared as best it could under the circumstances. 

Yet Phillips and Dr. Randolph Holmes, a Los Angeles-based physician who chairs the California Society of Addiction Medicine’s government affairs committee, wondered aloud whether San Diego County will eventually have the resources it needs to ensure SB 43 results in more people receiving care. 

Absent a dramatic increase in local facilities, behavioral health staffing and other resources, both said the law could simply be a paper promise to connect more people with treatment. 

“The implementation of this is really going to be based on how we are able to build and maintain capacity,” Phillips said.