Mental Health Services Deemed Disconnected and Dysfunctional

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.”