Gutting mental health

Labor Day may mark the traditional end of summer, but extensive budget cuts to Sacramento’s already ravaged public mental-health system will continue into the fall, with devastating consequences as emergency rooms and the county jail pick up the slack, according to county officials.

Last week, the budget ax fell once again on the Department of Behavioral Health Services, which cut 50 of its 100 psychiatric beds and closed its crisis unit at the Sacramento County Mental Health Treatment Center. That’s against a backdrop in which 4,500 mental-health clients have already stopped receiving medication support, psychiatric care and therapeutic services from the department’s Regional Support Teams in July.

“It’s scary,” said John Buck, executive director of Turning Point Community Programs, a nonprofit organization contracted with the county to run Northgate Point, one of its five RSTs, as well as its own community mental-health programs. “We’ve never seen a situation like this,” Buck continued. “To close the [psychiatric treatment] beds—it was either that or dismantle all other adult mental-health care in the county. It was Sophie’s Choice, and to me, some care is better than no care.”

In doing so, the county shaved $9.6 million off its bottom line for the mental-health department. But there are costs—in both human and financial terms—to cutting mental-health treatment. Law enforcement is but one agency bearing the brunt of the cuts.

“Unfortunately, the mentally ill are a serious social problem that requires attention and care,” said Capt. Scott Jones, commander of the Sacramento County Main Jail. “Many times, mental disability, either temporary or permanent, manifests itself outwardly in criminal behavior, for which law enforcement has to intervene. This means that they end up in jail and as an additional burden to the criminal-justice system.

“To the extent that society can intervene before the criminal behavior,” Jones continued, “everyone is better off, and from a strictly financial perspective, intervention is by far a more fiscally prudent approach. But with the closure of facilities, this will be less and less of an option and more folks will end up in jail, tying up law-enforcement resources.”

Scott Seamons, vice president of the Hospital Council of Northern and Central California, which represents nine emergency rooms in Sacramento County, said the choice to close the crisis unit and cut the beds at the treatment center will have a “negative and dramatic” impact on ERs across the county.

“We know this because we’ve been tracking psych admissions since the county started closing its crisis unit on the weekends, beginning Memorial Day weekend,” said Seamons, who reported that the Mental Health Treatment Center has been quietly diverting patients on the weekends to local ERs since Memorial Day as a “practice run” for closing the unit altogether.

Between June and July, emergency rooms saw 716 patients diverted to them, and tracked their comings and goings. Seamons said they tended to stay in the ER about a day and a half, awaiting placement to Sierra Vista, Heritage Oaks or one of the other private psychiatric hospitals in the area. But here’s the kicker: These patients get no treatment while in the ER.

“We’re not set up for it,” Seamons said. “We don’t have psychiatrists who come by to assess them. So they just sit there, waiting. It’s an untenable situation.”

Additionally, while the average wait time for anyone coming to an ER for routine care—non-chest-pain-related care, for example—is four hours; now, with the influx of psychiatric patients, the wait time has risen to 6.8 hours.

“That should give everyone in this community pause,” Seamons said, adding that the average number of psych patients in an ER unit at any given time is 12, while prior to the county’s move, it was four or five.

To Seamons and Jones, this is nothing less than a public-safety issue.

“How can the county say otherwise?” Seamons queried. “It’s irresponsible. Once the crisis unit closes, they will send all their patients to us and that just sends everything off the charts. These people will end up on the streets. We contend that this issue is as much a public-safety issue as anything the county has ever considered, and they should hold off implementing this change until mitigating measures have been put in place to accommodate these patients.”

Sacramento County’s allocation to the BHS budget for 2009-10 was $1.2 million. That isn’t going to change, said Ann Edwards-Buckley, director of the Department of Behavioral Health Services, which covers mental health as well as providing drug-and-alcohol recovery services and public health information. The $1.2 million is for the mental-health budget only, and funding from Proposition 63, the Mental Health Services Act, has held steady at $27 million annually.

However, the declining economy and subsequent reductions in sales-tax revenue, vehicle license fees, and Medi-Cal reimbursements from the state and federal governments have blown a $20.5 million hole in the budget, and the county doesn’t have funding to fill the gap.

“We’re facing severe, severe cuts, in all areas—but not from the county general fund,” Edwards-Buckley said. “Because of the shortfall in the county general fund, it is unlikely that the board will allocate extra funds to me to take up the shortfall,” she continued.

BHS said it had no choice but to close the treatment center’s crisis unit and cut beds, given a last-minute state reduction of $9.6 million in managed-care funds from which the treatment center is funded—a 50 percent reduction. Because MHSA funds cannot be used to fund acute care, said acting director Mary Ann Bennett, it was not an option to use Prop. 63 funding to cover the budget cut. Additionally, the department had another mid-year hit of $1.2 million in realignment funding.

Bennett said that in order to provide at least a modicum of care to the county’s remaining 4,000 clients, as well as assist the patients displaced by the cuts in regional services, the treatment center had to be cut.

“By having a continuum of services that includes a viable outpatient component, we are preventing more costly hospitalization or crisis treatment,” Bennett said. “When we dealt with the outpatient reductions in fiscal 2008 and 2009, we redesigned programming and were able to utilize MHSA funds to mitigate the impact. However, MHSA dollars, by law, cannot be used for acute care. Therefore, in order to maintain a viable continuum of service, it is necessary to reduce the capacity and adult crisis unit at the treatment center.”

While the cuts are almost entirely a function of state budget reductions, District 1 Supervisor Roger Dickinson said the board is “actively looking” at approaches that could preserve the crisis stabilization unit—“although there’ve yet to be any good ideas identified.”

“But losing the [unit] has us all very, very, concerned,” he added.

Many are taking issue with the county’s description of what’s in place now as a “viable continuum of service,” but no matter—all you have to do is take a look in Seamons’ emergency rooms to see even a partial closure of the crisis unit isn’t working.

The crisis is likely to get worse before it gets better, Seamons noted: When the H1N1 flu hits in October and the ERs are packed, and the mental-health clients are packed in there too, “Just wait—it will overwhelm the system. We won’t be able to manage it all. It’ll be disaster. We’re just setting ourselves up for disaster.”