Trouble Growing In Fresno

Critics cite problems after closure of mental-health center

From The Fresno Bee by Pablo Lopez, December 19, 2009

Six months ago, Fresno County closed its only psychiatric-crisis center to save money, forcing police to take potentially dangerous people to hospital emergency rooms instead.

The result has been a disaster, critics say, as hundreds of mentally ill patients flooded the county's already-busy emergency rooms -- overwhelming unprepared doctors and nurses.

Many hospitals saw caseloads double, but critics say there are other troubles besides the sheer volume of patients:

Emergency rooms are not secure enough. Most hospitals do not have a safe place to isolate patients in emergency rooms, even as they see an increasing number who are violent.

Police are being taken off the streets. Officers can be tied up for hours -- and in some cases days -- guarding out-of-control patients brought to hospitals for evaluation.

It's costing taxpayers more. Hospitals are referring more patients to expensive inpatient care. The county must pay the bill for indigent patients -- which is common among those with mental illness.

Mistakes are more likely. Advocates for the mentally ill say experienced mental-health workers should be evaluating the psychiatric patients -- not emergency-room personnel.

The unprovoked killing this month of a delivery driver in Fresno may be an example of such a mistake, they say. Three days before the killing, police had picked up the suspect on a mental-health hold, and he was taken by ambulance to Community Regional Medical Center.

He was back home within 12 hours.

"The system is in total meltdown," said David Weikel, executive director of Mental Health America of the Central Valley, an advocacy group.

A risky move?

Fresno County isn't alone in closing crisis centers. With budgets shredded by the recession, counties statewide have turned to emergency rooms as the first stop for people with mental illness.

In Fresno County, the transition occurred over the objections of mental-health advocates. At a hearing in April, they warned the Board of Supervisors of the consequences of closing the county's Psychiatric Assessment Center for Treatment.

"People are going to end up on the streets or in the jails," Weikel said then.

The 24-hour, locked assessment enter -- commonly known as PACT -- was designed for patients experiencing psychotic episodes.

The center was equipped for people to stay for up to 72 hours or longer for evaluation and treatment. It served 4,454 people in fiscal year 2008-09, and 9% stayed at least 72 hours.

From throughout the county, law-enforcement officers brought people who were in psychiatric crises -- many threatening to hurt themselves or their families.

The crisis center saw patients with serious mental illnesses, such as bipolar disorder and schizophrenia. Psychiatrists, psychiatric technicians and other trained staff were on duty.

Under the county's new plan, however, emergency rooms are the first stop for high-risk patients detained by police involuntarily under the "5150" provision of the state's Health and Welfare Code.

Generally speaking, the provision allows a mentally ill person to be detained for up to 72 hours if deemed to be a danger to oneself or others or gravely disabled. To hold someone longer, a psychiatrist must find that there is still a danger.

Fresno police officers responded to 2,872 of these "5150 calls" in 2009, said Robert Nevarez, the city's deputy police chief. Once police detain a mentally ill person involuntarily, officers have no say as to whether that person is hospitalized or released back to the street, Nevarez said.

All too often, hospital personnel release them within hours -- and police are frustrated, he said.

"We are police officers, not mental-health experts," Nevarez said. "We have to rely on their expertise."

But hospitals are "simply not positioned or equipped or staffed or funded to do this kind of work," said Lynne Ashbeck, regional vice president of the Hospital Council of Northern and Central California, based in Fresno.

Fresno County Supervisor Henry Perea said recently that the county had no choice but to close the crisis center, because there's no money to fund it.

"What you're seeing is a total collapse of the entire system -- not just mental-health funding," he said, noting that Fresno City Hall has had to cut police and fire budgets as well.

A recipe for tragedy

The parents of Joey Jesse Lopez -- the man suspected of fatally shooting delivery driver Richard Hernandez -- have said the tragedy could have been avoided.

Hernandez, married and the father of two children, was shot in the back for no apparent reason Dec. 7 as he delivered beer to a central Fresno convenience store.

Three days before the killing, police had detained Joey Lopez on a 5150 hold after his parents called 911 and reported their son was acting bizarre and strung out on drugs. An ambulance took him to Community Regional Medical Center, but he returned home within 12 hours, his parents said.

Their son is mentally ill, the Lopezes said. He sees imaginary things and hears voices, and has been in and out of prison so many times that he's become paranoid of anyone in uniform, they said.

In the past, Joey Lopez had gone to the county's crisis center after police picked him up on a mental-health call, his parents said. About seven years ago, he was hospitalized for about a week, they said.

"They took care of him, fed him and gave him medicine," said Lopez's mother, Theresa Lopez of Fresno. He was able to function again and get a job at a tire store, she said.

Privacy laws prevent police or Community Regional Medical Center from discussing Lopez's medical care, including reasons for his release, but his parents said they wished he had been hospitalized, like he had been before.

Lopez, 27, has been charged with murder in the killing of Hernandez. Co-defendant Christopher Gonzalez, 20, faces charges of being an accessory after the killing and evading arrest. They pleaded not guilty Friday in Fresno County Superior Court.

The Lopezes said the county's new system let them down.

"We pay taxes so people can get help," said Joe Lopez, who paints cars and trucks for a living. "When my son needed help, they threw him out on the streets."

High hopes

That's not the kind of situation county officials expected when they shuttered the psychiatric crisis center.

When the closure was proposed, Giang Nguyen -- who was then the county's behavioral health director -- said hospitals would get help shouldering the mental-health patient load.

Under the county's plan, a mobile response crisis team of county workers would respond to calls from hospitals when a mentally ill patient was brought to the emergency department for evaluation.

But the plan didn't work, hospital officials say.

The county has only two of these two-person teams -- consisting of a case manager and licensed mental-health technician -- available on weekdays. Only one team responds to calls on nights and weekends.

One call can tie the team up for hours, Fresno hospital officials said. As a result, hospitals in Fresno no longer rely on the county teams.

Nguyen -- who had run the department since 2005 in a period of budget-slashings -- started a job Nov. 1 as a deputy director in the community services division at the California Department of Mental Health in Sacramento. She could not be reached to comment.

Within a couple of months of the center's closure, hospitals throughout the county saw mental-illness caseloads skyrocket. Many have seen patient volume double.

Saint Agnes received 320 patients who were on a 72-hour hold in 2008. As of Nov. 30 this year, the hospital has had more than 600, said hospital spokeswoman Kelley Sanchez.

At Community Regional Medical Center in downtown Fresno, emergency department staff are seeing twice the number of mentally ill patients now as before. Each day, 16 to 20 such patients come through the unit, said Dawan Haubursin Utecht, chief executive officer at Community Behavioral Health Center. Utecht runs the behavioral health center, a 61-bed psychiatric treatment facility operated by the hospital.

The behavioral center provides staffing 12 hours a day for the emergency room's psychiatric patients, Utecht said. Because of the increased caseload, a second 12-hour shift is being added, she said.

Community Regional Medical Center is the only hospital in the county with a locked, dedicated emergency area for psychiatric patients, Utecht said. Elsewhere, potentially violent and disoriented mentally ill patients wait to be seen with the general emergency department population.

And the locked unit at Community Regional can't always hold all the 5150 patients, Utecht said.

Because of the increasing number of patients, Saint Agnes is considering a redesign of its emergency department that would include a special unit for psychiatric evaluations, Sanchez said.

But there's little incentive for hospitals to make room for the patients.

Fresno County doesn't reimburse hospitals for mental-health evaluations, and more than a third of the patients are indigent -- with no government or private insurance to be billed, according to the county. By law, hospitals cannot turn away emergency-room patients who can't pay.

A costly change?

From the county's perspective, closing the psychiatric assessment center saved money -- at least in the short term. It cost $5.9 million a year to operate, county officials said.

But some now question how much it's costing taxpayers for the county not to have a psychiatric-evaluation center.

The county still provides mental-health services. For example, there's a 14-bed locked unit for inpatient psychiatric treatment, a 14-bed unlocked detoxification unit for people with substance-abuse problems and mental illness, a walk-in urgent-care center, and outpatient clinics for treating the chronically mentally ill, as well as long-term residential treatment units.

But with the closure of the crisis center, the county is paying more to hospitalize mentally ill patients. Records show that among patients for whom the county is financially responsible, 888 were hospitalized in 2008. This year, through Nov. 30, the number was 1,326.

Hospitalizations cost Fresno County $4,693,974 last fiscal year. In four months this year, the county has already spent $2,238,114 -- a rate of about 40% higher.

The numbers don't include the use of the county's 14 beds for patients who need treatment.

When the county opened the crisis center in 1991, it was intended to prevent some of the hospitalizations that were occurring when patients were taken directly to hospitals for evaluation, said Donna Taylor, interim director of the county's Department of Behavioral Health.

The reasoning was that hospitals wanted the psychiatric patients moved out of emergency rooms as quickly as possible, she said.

That appears to have been the case in Kern County, where a decision was made in March to open a psychiatric assessment center and get mentally ill patients out of the county hospital's emergency room.

"We have already saved just short of a million dollars in inpatient costs just since July 1," said Bill Walker, crisis services administrator in Kern County.

Walker said decreasing hospitalizations was not the reason for opening the assessment center in Bakersfield. But it was a welcome result. The hospital space was not secure enough to handle a growing caseload, he said. "We had patients who could sneak out the side door. We all agreed we needed a safer environment for our patients," he said.

Indeed, security is a concern in many hospitals -- and an added cost for communities. While most mentally ill patients are not violent or a risk to other patients or hospital staff, the potential is there. Some smaller hospitals have no security guards in their emergency departments.

Police officers often must stay with patients to protect hospital staff -- and to make sure the patient doesn't just walk away.

Reedley Police Chief Steve Wright said when the psychiatric assessment and crisis center was open, officers could drop patients off and leave. With its closure, they now follow an ambulance to a hospital and stay there until the patient is deemed safe.

"That could tie up an officer for hours," he said. "It also impacts our overtime budget." In one recent case, a 5150 patient was so out of control that officers had to stay with him 24 hours a day for more than a week, Wright said.

"From my perspective, I have not seen any [positives] from the new system," he said.

What now?

Taylor, the interim behavioral health director, is evaluating Fresno County's new system.

"We are working with hospitals and asking, "What is it you need from us?" said Taylor, who has worked in the county's mental-health system for years. Before her temporary appointment as director last month, she was assistant director for the Department of Children and Family Services.

One complaint she's heard: Hospitals say there are no mechanisms to make sure patients get treatment when they're released from emergency departments, she said.

She's proposing a program that would use county staff to follow-up with mentally ill patients released from emergency rooms to link them to services. She would use staff from an underutilized voluntary detoxification unit, she said.

Taylor also plans to hire a senior licensed clinician to work with law enforcement, accompanying them on 5150 calls. She hopes to start the pilot program in January.

Mental-health officials across the state are watching what happens in Fresno County.

Kings County has been using emergency rooms to evaluate 5150 patients for more than a dozen years, said Shanon Quinn, program manager for Kings View Counseling Services, a provider of behavioral health care. It has been working without any major incident, he said.

Kings View works closely with law enforcement, and once a 5150 patient is released, employees call police to let them know, he said. They also make home visits and call patients.

Quinn isn't ready to judge Fresno County's system. "The verdict remains to be seen," he said.

As in Fresno County, Sacramento County began sending psychiatric patients placed on 5150 holds to hospital emergency rooms in October, when it ended its version of a crisis intervention unit.

Scott Seamons, an official with the Hospital Council of Northern and Central California, said hospital officials in Northern California are taking special interest in Fresno County's decision to close its crisis center. They also are following news accounts of Hernandez's death.

Seamons said a patient accused of killing someone "is the fear that keeps us awake at night."

Source: The Fresno Bee

Link: http://www.fresnobee.com/1049/v-print/story/1755358.html