FORGET NOT: Mental-health advocate Ann Eldridge acknowledged the department had major problems, but noted it’s helped hundreds of families over the years.

Paul Wellman

FORGET NOT: Mental-health advocate Ann Eldridge acknowledged the department had major problems, but noted it’s helped hundreds of families over the years.

Mental Health Services Deemed Disconnected and Dysfunctional

Two Reports Take County Department to Task

Thursday, May 23, 2013
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It’s hardly a state secret that the county’s Department of Alcohol, Drug and Mental Health Services (ADMHS) is — and has long been — seriously out of control. But it took two private consulting firms specializing in healthcare services to explain in bureaucratically vivid detail just how colossally dysfunctional it’s really been. The two reports conducted by the two firms — at a cost of $175,000 — were officially released last week and were the subject of an exhaustive public hearing before the county supervisors this Tuesday.

Despite the tsunami of damning details presented in each report, the county supervisors —and many of the stakeholders who testified — remained strangely optimistic that the possibility of real change actually existed. Emily Allen, a homeless-rights advocate associated with the Legal Aid Foundation, recounted how she’s frequently been asked how the studies— whose contents had been the subject of intense speculation and rumor — differed from numerous grand jury reports issued over the years blistering the shortcomings of ADMHS. “What I find that is new is this opportunity we have now,” she said. Cecilia Rodriquez, the executive director of CALM (Child Abuse Listening Mediation), talked about the “hope” and “momentum” offered, in part by the issuance of the reports, and even more by the apparent commitment from the supervisors to address a long-festering problem.

Some speakers objected the reports failed to acknowledge the strengths of the department, but there was consensus that its shortcomings were captured accurately. Supervisor Janet Wolf, who took exception to some of the fixes proposed, said she was struck by the use of the words “hope, opportunity, and trust” by speakers who typically can be counted on to rail against the department. Because of that, she said, she wouldn’t “step in the middle” of the healing process proposed by the consultants.

These firms concluded that ADMHS — which provides a wide range of therapeutic services to about 12,000 residents a year — has been defined by “a culture of dysfunction” for many years, careening from one serious crisis to the next. Rather than working collaboratively with the multitude of community service providers on whom they rely to get the job done, departmental leaders have opted for a top-down “command and control” approach mode that’s proved alienating in the extreme — to private contractors, to frontline mental health workers, to other county departments, and to county hospitals.

Despite “pockets of excellence” strewn throughout the department, the consultants found that actual services provided have been declining. It takes more than 10 days, they found, for nearly 60 percent of people seeking mental health or substance-abuse help to be seen by anyone in ADMHS. But for first-time clients hoping to see an actual psychiatrist, the wait is much longer. For adults, the average time is 66 days. For minors, it’s 73.

For patients and families seeking to navigate any of the many programs that make up the county’s system, said Dr. Andrew Keller of TriWest consulting group, the challenges go beyond daunting. “At the system level, the outpatient continuum of care is not designed to meet the needs of people served,” he wrote,“and is striking in its level of disconnectedness.” Even so, he said, many ADMHS workers are committed to their mission and want to see changes made. But anyone seeking to rock the boat, he noted, risked the possibility — real or imagined — of retaliation. A “culture of reactivity and negativity,” he charged, interferes with “customer oriented” service reforms.

BRASS TACKS: Keller and his team of consultants met with more than 400 employees, community stakeholders, and department personnel in drafting their report. He noted that his own requests for ADMHS planning and policy documents were repeatedly met with “delays and partial responses.” The problems afflicting ADMHS have grown so entrenched and widespread, he reported, that “no piecemeal” fixes can hope to succeed. Nothing less than a massive makeover of the department’s cultural DNA will suffice.

In analyzing the department’s shortcomings, Keller acknowledged, ADMHS has, in fact, suffered real and repeated trauma. In 2008, ADMHS was notified it had been overcompensated by the state Department of Mental Health to the tune of $31 million and would have to pay it back. But even before then, the department had serious structural issues. Despite combining programs dealing with the mentally ill and with substance abuse into a new department, the two missions never fused. To this day, Keller charged,ADMHS has never crafted meaningful policies or programs that addressed the stubborn reality that serious substance abuse issues are endemic to those fighting serious mental illnesses. Programs seeking to address one, but not the other, have little chance of success.

Nowhere is that incongruity more evident than in the county’s psychiatric health facility (PHF), the only place in Santa Barbara County where people deemed a potential danger to themselves or others can be placed in involuntary lockdown for 72 hours and medicated. Because of state regulations, the PHF unit is not equipped — or licensed — to handle patients in the throes of a mental-health crisis who also have taken drugs or alcohol. The county can, however, send such patients to two facilities in Ventura, though one has capacity limits and for the other, there’s no financial reimbursement to the county.

The issue came to a head two years ago when a 46-year-old Santa Maria man — who had been checked into the PHF despite the presence of methamphetamines in his system — died while being held in seclusion and restraints. His death nearly got the PHF unit shut down by federal regulators, and that close call precipitated the recent call to action by county administrators and elected officials. The report on the PHF unit, conducted by Health Management Associates (HMA), documented the extent to which the shortage of involuntary psychiatric beds — only 16 countywide — has created serious logjams of the severely mentally ill in hospital emergency rooms and the County Jail. Cottage Hospital sees 8-10 seriously mentally ill patients a day, one to two of whom might be eligible for involuntary “5150” holds. Only certain county mental health workers are empowered to make that determination, and according to the HMA report, the criteria upon which those decisions are made seem arbitrary and capricious to law enforcement, patients, and medical professionals.

The amount of time required to clear a patient for PHF admission has increased, creating problems for emergency room administrators, not to mention the patients themselves. Likewise, the report found that the length of time most PHF patients are staying has expanded from nine to 12 days. Some are held there because there’s no place else to put them, thus exacerbating a shortage of bed space that’s already acute. This causes problems for County Jail, where at any time, 100-150 inmates are mentally ill enough to be taking psychotropic medications.

When PHF is full, the jail keeps its PHF candidates in four isolation cells with soft walls, no sink, no toilet, and grated drains on the floor for urination and defecation. The HMA report concluded that even if the county were to fix all the many problems afflicting the PHF unit, it would still be extremely expensive to operate, still serve a very limited population, and still offer a constricted range of therapeutic options. But if a hospital were to take it over, the report suggested, the range of services the PHF could be licensed to provide would expand significantly.

In Santa Maria, for example, Marian Regional Medical Center is now undertaking such an effort. But Marian is too far from the PHF unit for its license to apply. Cottage Hospital, by contrast, is not and could theoretically take the PHF unit under its wing. Cottage Hospital’s Todd Cook was on hand Tuesday, telling the supervisors, “We’re with you.” But in an interview afterward, Cook noted that Cottage had never been asked about taking over the PHF function.“There’s been no conversation,” he said, adding, “I can’t say we’re exploring anything.”

SILVER LINING: To the extent there was a sore spot to the day’s discussion, it centered around the fate of the PHF and whether the supervisors should authorize ADMHS acting department head Takashi Wada to circulate a “Request for Information” to surrounding hospitals or private health-care contractors to determine if they could run it cheaper or better. Members of the county’s public employee unions spoke out against this option, as did Supervisor Janet Wolf. Likewise, Wolf and Supervisor Peter Adam expressed reservation about hiring Keller’s consulting firm — to the tune of an additional $100,000 — to “coach” the county through the next six months. (They both argued against “management by consultant” and that the county should hire a new director for ADMHS. Currently the two top positions are vacant because of resignations.)

In that time, serious fence-mending sessions are supposed to transpire between ADMHS and its many disaffected and distrustful stakeholder groups and private service contractors to establish some sense of “shared vision” and effect the cultural transformation of the department. From there, it will be up to administrators to devise clear and coherent policies and “best practices” and to integrate the wide range of services ADMHS now supports into a “continuum of care.”

To make this happen, the board approved the creation of three new executive positions, one temporary. No new funds ostensibly will be required; these positions will be financed with savings derived by not hiring a new department director — and second-in-command — and leaving that function to Public Health chief Dr. Wada to handle as he has the past six months “part-time.”

The debate over bureaucratic Xs and Os briefly threatened to get testy, with Supervisor Steve Lavagnino stating, “I don’t want to be spinning our wheels,” and Supervisor Wolf retorting, “I don’t want motion for motion’s sake.” With all the talk of “hope” and “trust,” Wolf said she would trust the plan. Summing it up, Supervisor Doreen Farr stated,“What we all want is a comprehensive integrated system of care where no one has to wait two months to see a psychiatrist and where no one has to be sent out of town to get treatment.”


Independent Discussion Guidelines

No new funding required???? Two full time positions with benefits and a new temporary position are being offset by the cost savings of one department head that is paid $160K+??? Ah, the BOS must mean, no cost now, but when it comes time for quarterly budget adjustments, watch the numbers grow. Noble goals, cost money, County in the hole for millions (for the 4th straight year) and back to spend, spend spend.

BeachFan (anonymous profile)
May 23, 2013 at 8:44 a.m. (Suggest removal)

Disconnected and dysfunctional usually means an organization let its mission get too broad. Narrow the mission, target and audit results and expand only when ongoing resources permit you to do more of the above. Mission - target- audit.

foofighter (anonymous profile)
May 23, 2013 at 1:45 p.m. (Suggest removal)

Uhm.. its not an automobile factory we're talking about human beings and we already have shortage in mental health services. As to how it's being actually managed I won't guess. But crippling an already distressed department is not smart management of any kind unless your ulterior motive is to destroy it.

Ken_Volok (anonymous profile)
May 23, 2013 at 1:49 p.m. (Suggest removal)

It doesn't sound like the county supervisors were all that helpful.

Num1UofAn (anonymous profile)
May 23, 2013 at 2:42 p.m. (Suggest removal)

I am a retired from the County. I was a budget analyst in the Office of the County Administrator/Executive. Mental Health, Health Care, and Social Services were my budget units for many years.

The department of Alcohol, Drug and Mental Health Services receives only 4 percent of its revenue from the General Fund. Of the $60 million in revenue, $32.6 million comes from federal and state sources and Medi-Cal, Medicare and private insurance provide $36.1 million.

The budget is online. Put Santa Barbara County Budget and click on Alcohol, Drug and Mental Health in the search engine. On pages D-83 and D 84, one can find the expenditures, staffing and revenue in detail.

As for Ken_Volok's comment, right on, sir. We are talking about people here.

LHThom (anonymous profile)
May 23, 2013 at 2:47 p.m. (Suggest removal)

Spending money you don't have for results you can't document is not a plan either. Prioritize needs and get the top priorities done. That is how you deal with humans in a cost-conscious way.

Your plan of doing nothing but throwing more money at what is dysfunctional doesn't make sense. Why would you do that? This is about helping people -the targeted population, is it not?

foofighter (anonymous profile)
May 23, 2013 at 2:48 p.m. (Suggest removal)

"Talking about people" doesn't mean waste and mismanagement are acceptable.

JohnLocke (anonymous profile)
May 23, 2013 at 6:20 p.m. (Suggest removal)

I bet there's a lot of duplicated effort within and between County Departments.

Ken_Volok (anonymous profile)
May 23, 2013 at 6:25 p.m. (Suggest removal)

Me, too. That would be a job for a CEO, County Manager, whatever, with power to change things.

JohnLocke (anonymous profile)
May 24, 2013 at 9:04 a.m. (Suggest removal)

County Mental Health has for many years tried to do all it can to refuse services to many mentally ill residents by saying they don't meet the specific criteria of Mental Health's "target population". The fact that it takes so long evaluate someone who is not a danger to himself or others is deplorable.

As a retired county social worker I witnessed this dysfunction year after year. This dysfunction was caused by the policies implemented by management, not by most of the line staff who performed their jobs well despite the obstacles in their paths.

buckwheat (anonymous profile)
May 24, 2013 at 9:12 a.m. (Suggest removal)

Duplication of services:

That is a goal for the Board of Supervisors to set with the county CEO, whom they just terminated so it won't be happening soon.

But should be on the next CEO mutually set agenda with the board of supervisors, whomever that might be. Voters can let their supervisors know this is an important consideration for them to pursue.

foofighter (anonymous profile)
May 24, 2013 at 9:14 a.m. (Suggest removal)

Buckwheat, I bet a lot were policies implemented by politicians so they could turn around and cry that it's not working after they sabotaged it.

Ken_Volok (anonymous profile)
May 24, 2013 at 11:57 a.m. (Suggest removal)

More likely the "policies" were political bandaids dispensed to put out a short-term fire, without thinking how they ultimately would fit into the entire system or get paid for over time.

This is why it is critical at this point of fiscal breakdown to refigure the entire mission, priorities and audit for cost-effective results. No biggie. Businesses do this all the time.

Unions, with their howls protecting jobs first, last and always, are the only stumbling block to get this system up and functioning on the dollars they already get.

Tell them to get out of the way, you have some serious business to do and that is protecting the clients served; not the union members paid.

foofighter (anonymous profile)
May 24, 2013 at 12:22 p.m. (Suggest removal)

The CEO was terminated because she tried to actually manage the organization. BoS allowed department heads to come directly to them and undermined the CEO. Blame the BoS, again, for the failure of the County to operate properly.

JohnLocke (anonymous profile)
May 25, 2013 at 8:28 a.m. (Suggest removal)

I got the impression Waller was doing an excellent job as well. Supervisors with a history of micromanaging will have a hard time finding, let alone retaining a new CEO.

Creating a revolving door in county administration due this sort of board member interference is not only expensive, it is sheer folly. Time for some more solidly business-oriented supervisors and not political grand-standers.

foofighter (anonymous profile)
May 25, 2013 at 8:46 a.m. (Suggest removal)

Elections are coming. We'll see whether the SB (County and City) voters get it. Care to place a bet?

JohnLocke (anonymous profile)
May 26, 2013 at 10:08 a.m. (Suggest removal)

Keep getting the message out and they will.

Identify the public sector union endorsed candidate first, so voters know they will be voting against their own self-interests and getting more of the same at the same time.

Then work on taking partisan politics out of non-partisan races or else expect the same results too.

Respect the public sector unions still run the best ground game in town on election day, so make sure you get everyone to go to the polls to counter their dragoon "provisional" voting efforts.

The unions are hungry and they want their people in. Don't let them. Starve them at the ballot box, if you want change you can believe in.

Yes, this time find the candidates that best represent your views and support them with time, money and walking the grass roots precincts efforts on their behalf. That is what the unions do.

foofighter (anonymous profile)
May 26, 2013 at 10:24 a.m. (Suggest removal)

Preaching to the choir, foo. Hopefully others will listen.

JohnLocke (anonymous profile)
May 27, 2013 at 9:05 a.m. (Suggest removal)

Make it simple! That's been my motto, and it seems to work. It requires being "very specific" in all of your requests for better mental health services at PHF, line item by line item, to the nitty details. Nothing less than this is acceptable. An adjunct committee can put this together and present it to the parties involved. "Be the results!" Don't settle of anything less.

suzyque (anonymous profile)
May 27, 2013 at 12:12 p.m. (Suggest removal)

I've been posting since this Board Majority changed the rules so that dept. heads report directly to them, not the CAO, so politics have become an even greater hindrance to effective operations than ever before. Which is why this style of weak CAO is declining in agencies across America. Yet, SB County folks keep electing the same people who are directly responsible for the mess we are in.

BeachFan (anonymous profile)
May 28, 2013 at 3:15 p.m. (Suggest removal)

Hence the problem. We are by majority a liberal/progressive community therefore our natural inclination is to vote Dem (obviously the local Republicans can't even muster up anybody born post Enlightenment). Hence The Dem Party has become the establishment party, in which votes are very often taken for granted.
The only real solutions are for new blood in the Dems or a new indie/third party to at least put their feet to the fire if not win.

Ken_Volok (anonymous profile)
May 28, 2013 at 3:46 p.m. (Suggest removal)

A little harsh on the Republicans, Ken. There are some reasonable ones (not many, or not visible), but they don't get much press - not nearly enough fire and brimstone to satisfy the media. I'd love to see a viable Centrist party. Fat chance.

So in the meanwhile, great. New blood. Vote against Taxin' Jackson, Pelosi-parrot Capps, Opportunist Das, East Coast Helene, Salud "the Pope" Carbajal, Sheriff Bill "only the bad guys get to carry guns", and all the other members of the local Demafia next chance you get. I sure will.

JohnLocke (anonymous profile)
May 29, 2013 at 4:11 p.m. (Suggest removal)

I know there are reasonable Republicans as I know a few and even a few I would vote for; but they most don't wish to be visible or run having other interests in life. In addition, being brief and not making generalizations can be challenging.

Ken_Volok (anonymous profile)
May 29, 2013 at 4:27 p.m. (Suggest removal)

Outsiders wanting contracts with the county making the noise in this story.

bobbydias (anonymous profile)
June 10, 2013 at 6:25 p.m. (Suggest removal)

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