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Contra Costa Mental Health Services Lacking 

http://www.bayarea.com/mld/cctimes/living/health/3385417.htm

Posted on Sun, Jun. 02, 2002


Mental health breakdown: Contra Costa's ill scrounge for scarce treatment

By Peter Felsenfeld
CONTRA COSTA TIMES

Doctors identified Dave Kahler's 31-year-old son as a manic depressive eight years ago, and the troubling journey began.

The diagnosis propelled the family into Contra Costa County's mental health system, where they found an overloaded bureaucracy struggling to help some of the county's most fragile residents.

"The system is seriously broken, and God help the people who have to use it," said Kahler, who became an advocate for the county's mentally ill as the Contra Costa chapter president of the National Alliance for the Mentally Ill.

The National Institute of Mental Health estimates that slightly more than 7 percent of a given population suffers from a serious mental disability. If that holds true, Contra Costa has as many as 45,000 mentally ill residents.

From top to bottom, through every stage of the treatment continuum, rampant deficiencies force the 10,000 residents who seek treatment annually to compete against each other and scrounge for scarce resources.

Faced with few residential treatment options, Contra Costa health officials ship many mentally ill patients to distant counties, far from familiar doctors and family. Other individuals languish on the streets for lack of facilities.

Harried case workers balance unmanageable loads. Overwhelmed crisis specialists find themselves cornered into making snap critical decisions.

The ubiquitous mantra: No beds, there are no beds here.

Despite state funding limitations, most other Bay Area counties dedicate more money to their mental health programs. Contra Costa's $27 million adult program budget is lower than that of such smaller counties as San Mateo ($34 million) and Solano ($36 million), as well as Santa Clara ($64 million) and Alameda ($101 million).

Contra Costa's mental health options lag behind other Bay Area counties in several other key areas as well.

In a county lagging behind others in funding and facilities to treat the mentally ill, most people opt to suffer silently rather than endure the societal stigma attached to their condition, Kahler said. Those who do get help, such as his son, tend to be those with a strong family structure to support them.

But, Kahler said, "They have to be very aggressive. It helps if they're intelligent and speak English. If a mentally ill person doesn't have an advocate, they're preordained to go untreated."

Staff buried in work

For most patients, entrance into the public mental health arena involves a stint at Psychiatric Emergency Services, the county's crisis center. Abutting the regional medical center in Martinez, the facility plays home to a turbulent slice of life most people never experience.

Here, specialists face a 24-hour deadline to calm and evaluate people suffering severe psychotic breakdowns. Many are admitted high on crack, heroin, methamphetamine and alcohol. Some patients enter willingly; more than half are escorted involuntarily by law enforcement under California Penal Code 5150, meaning they present a danger to themselves or others.

Fifteen years ago, the center's staff gave each client considerable attention both on site and through follow-up consultations, but those days are long gone, said director Linda Kirkhorn.

In the past five years alone, caseloads have increased 20 percent while staff levels have stayed the same, often placing specialists under the gun to determine a patient's fate quickly, Kirkhorn said.

Any direction the staff recommends is fraught with pitfalls, starting with the most extreme patients who require hospitalization. When fully staffed, the psychiatric ward at the Martinez hospital next door offers 44 beds. Staff shortages often drive that number closer to 30, and those beds are full several times a week, Kirkhorn said.

The county's 28 residential treatment beds are routinely full as well.

So crisis staff members sometimes face a vexing choice: Send patients to remote facilities or allow them to walk out the door.

"Some folks literally beg not to be sent away," Kirkhorn said. "When the bed situation's tight, we might make riskier decisions to send people out. It's a fact."

Crisis center specialists recommend case management for many clients composed enough to return home. The county's case workers meet regularly with clients, keeping them on track with medication and providing guidance on myriad personal issues, such as housing, job training and financial matters.

Like most preventive health measures, case management represents an inexpensive and humane form of treatment designed to avoid the future need for emergency services.

But the outpatient system is backlogged with patients, and only the most severely ill receive a case manager. Most patients walking out of the crisis center are stepping into a void where there is no safety net.

"Twenty-six case managers for a county with 900,000 people is appalling. It's truly pathetic," said Donna Wigand, director of Contra Costa Mental Health Services.

Out on their own, many of Contra Costa's mentally ill cycle from homeless shelters to jails to emergency rooms, Wigand said.

No stepping stones

Health experts regard residential care, both locked facilities and those providing an emphasis on treatment, as important stepping stones in the transition from acute care to independent living. Without these types of facilities, Contra Costa residents face a rocky path to recovery, said Victor Montoya, Contra Costa's adult program chief.

"When individuals in highly structured environments are ready to take a step forward, there's a critical window of opportunity," Montoya said. "It's tough for us to provide those steps, and people wind up digressing if they miss that window to integrate."

An in-county facility would free up not only hospital beds for gravely ill patients leaving the crisis center but dollars for county coffers. At any given time, roughly one-third of the residents clogging the beds at the psychiatric ward would qualify for a lower level of care, Wigand said.

Medi-Cal reimburses the county for psychiatric hospital visits involving acute cases, but the state stops paying as a patient improves. Uninsured residents sometimes spend months in the ward, relying on the county to pick up the $900-per-day tab, Wigand said.

Acknowledging the need, the Board of Supervisors set aside $900,000 three years ago to find a site and a contracted provider for a 16-bed residential treatment facility. To date, county staff members have investigated more than 100 locations but have come up empty.

"The biggest issue is most of them are out of reach financially," Wigand said. "We are experiencing the same thing anybody who wants to build a home goes through."

The inevitable "not in my back yard" attitude presents an obstacle. County health officials came agonizingly close, nailing down a property in Concord two years ago before residents blocked the sale.

Supervisor Mark DeSaulnier of Concord, who supported the residents, said he would support another center in his district if it blended better with the neighborhood.

"These are naturally difficult facilities to site, and that means you're just going to have to be more sensitive," DeSaulnier said. "But ultimately, it's a facility we need and this is a big county. I'm sure we'll find one."

In the meantime, the dearth of beds has forced local health officials to farm out many of their patients to other counties. Last year, 350 Contra Costa residents received care in facilities from Fresno to Angwin to San Jose.

The practice costs the county up to $85,000 per bed per year, with most stays lasting between six and 12 months, Wigand said.

"But the human cost is the most distressing issue," said Wigand, the county's Mental Health Services director. "We're sending people away from all of their support system, all of their family, all of their friends, and in many cases their case managers.

"Usually when you discontinue those relationships, there's a price to be paid. Treatment becomes much more difficult."

Pinole resident Bob Torres, whose 30-year-old son suffers from schizophrenia, a bipolar disorder and alcoholism, knows what it means to miss a loved one recovering far from home. Diagnosed in 1980, Torres' son has received residential treatment in Angwin, San Jose, Vallejo and San Leandro between jail terms.

He now lives at a Berkeley center, a welcome relief to the road-weary family.

"The traveling makes a tough situation for everybody," Torres said. "And I have a car. Just imagine the stress for people who don't have any money."

Statewide, most counties have resorted to long-distance care solutions at some time as populations grow out of proportion with existing mental health services, said Patricia Ryan, executive director of the California Mental Health Directors Association.

The trend flies in the face of prevailing accepted recovery models, Ryan said.

"The ultimate goal is to see a fully supportive rehab model where you keep somebody in the community, and provide ongoing support in the least restrictive environment possible," Ryan said.

Dr. William Walker, director of Contra Costa County's health services department, said the county mental health system is dependent on state dollars, and legislators haven't always felt pressure to increase funding. Services are expected to stagnate or be cut next year because of the state budget crisis, Walker said: This means more hard work for families looking for help.

"The population at large doesn't care much yet about mental health, and their numbers are relatively small when you're talking about legislative advocacy," Walker said. "Politicians can reduce mental health services and come up relatively unscathed."

The community care-based ideal will become even harder to achieve if Gov. Gray Davis follows through on his plans to patch the state's projected $23.5 billion budget deficit. One proposed solution includes slashing $42.6 million statewide from the Adult and Children's Mental Health Systems of Care program.

Contra Costa's share would total $1.2 million, estimates county administrator John Sweeten.

"Our whole approach to mental health has always been catch as catch can," Kahler said. "The system has been stuck together with Band-Aids and Scotch tape, so we've wound up with this crazy quilt that doesn't work very well."
 

Peter Felsenfeld covers Contra Costa County government. Reach him at 925-977-8506 or e-mail pfelsenfeld@cctimes.com.

* 2001 cctimes and wire service sources. All Rights Reserved.

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