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A Psychiatric Emergency in Contra Costa County

For years, Contra Costa County has ignored problems at its once-groundbreaking psychiatric unit.  Now the violence and aggression have reached a breaking point.

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At their August 6 meeting, supervisors appeared to address the grand jury report with a shrug. Only one supervisor asked a single question of the hospital administrators who were present: Director Anna Roth, Interim CEO Jaspreet Benepal, and Director of Health Services Suzanne Tavano.

"I think it would be good to give some specifics," said Supervisor Diane Burgis, a first-time supervisor who represents the eastern part of the county. "I think there's some frustration because people talk about things and sometimes they feel like it's just words. And I know from you all, that you're working on action items actively."

Benepal responded to the vague question with a litany of cosmetic improvements the hospital has undertaken at Psychiatric Emergency Services such as painting the foyer, ordering a new exterior phone for the outside waiting area, and installing new signage in front of the building.

Contacted by the East Bay Express for a response to the sharp increase in violence at Psychiatric Emergency Services, only one of the county's five supervisors, John Gioia, responded. "Conditions at PES have become unacceptable," he said. "I'm getting this issue on the Joint Conference Committee [a committee of prominent doctors, two supervisors and various stakeholders] agenda for the committee's next meeting where we can take some serious consideration of this."

At the meeting of that committee on February 3, hospital officials presented three options for upgrades at Psychiatric Emergency Services. But none of the alternatives presented would remove minors from the windowless and dangerous building and place them in a stable and safe place more conducive to freedom of movement and healing.

In their written response to the grand jury report, administrators did not fully disagree with any of the body's findings. They did, however, attempt to reframe some of the report's findings so they weren't quite so shocking. For example, administrators claimed that only a small percentage of children and adolescents stayed in Psychiatric Emergency Services for longer than three days. "In 2018, the average length of stay for youth in PES was 11.9 hours, with a median length of stay 11.1 hour," their response reads. "In total, eighteen of 1,601 youth spent more than 72 hours in PES in 2018."

Psychiatric Emergency Services loses money in this situation because Medi-Cal does not reimburse the hospital for confinements of minors longer than 23 hours and 59 minutes.

Despite the severity of problems at Psychiatric Emergency Services, it's worth noting that Contra Costa County has been forward-looking in the treatment of psychiatric patients in recent years. Contra Costa County opened Psychiatric Emergency Services 20 years ago, and at that time it was the state's first crisis stabilization unit. Even with its problems, Contra Costa County remains one of only 23 counties that operates such a unit.

Prior to the creation of such units in California, patients in psychiatric crisis were taken to medical emergency rooms where they received little psychiatric care. Despite acute psychiatric pain, patients would remain strapped to gurneys for hours and even days while they waited for transfer to an inpatient facility that was often in another county.

Contra Costa County also faces a challenging problem that all mental-health departments in the state contend with, a shortage of inpatient beds. In California, the number of psychiatric inpatient beds has been decreasing for 50 years, creating acute backups in psychiatric emergency facilities. In 1970, there were 413,066 beds in state and county psychiatric hospitals. By 2010, that number had shrunken to 43,318. And by 2014, there were only 38,847 beds statewide, according to the California Hospital Association.

Despite these challenges, mental-health providers elsewhere in the state have been very innovative in developing crisis-stabilization treatments that have been so effective that the need for inpatient beds has been greatly reduced.

The old model of warehousing psych patients was finally broken by Dr. Scott Zeller, who was then the Chief of Emergency Services at Alameda County's John George Hospital, which is about a half hour drive south of Contra Costa County.

Zeller devised a method that prioritizes immediate intervention with patients experiencing psychiatric crisis. Now known as the "Alameda Model," patients are assessed quickly and removed from the chaos of emergency rooms and taken to a place where treatment in a comfortable and relaxed environment can begin as soon as possible.  The Alameda Model has cut treatment delays by 80 percent, which in turn cut the need for inpatient beds and further hospitalization by 75 percent. In places where it's practiced, the Alameda Model has repeatedly demonstrated cost savings and increases in patient recovery.

According to Zeller, delaying treatment makes patient symptoms worse.  "There's always been an assumption that that's the way it has to be, but all of our research shows that you should evaluate and get them alternatives to hospitalization," he said. "It makes so much more sense."

Zeller has also advocated strongly for mobile-response teams as an effective aftercare practice to keep patients stabilized. He believes it is critical that patients either have access to clinics for follow-up visits or access to a mobile response team that can carry out assessments in the field.  

This is another area where Contra Costa County has been a leader. The county operates a mobile response team for children and adolescents. Available by phone, mental-health counselors are dispatched to homes, schools, parking lots, anywhere they're needed. They also stabilize patients over the phone. They also provide follow-up care for psych patients who have been recently discharged from hospitals. In 2019, county mobile response teams reduced pressure on Psychiatric Emergency Services, clinics, and hundreds of families by treating patient crises early.

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