I have told this story before here, but it bears repeating. In 2011, shortly after our then seven-year-old nephew came to live with us, he experienced some serious mental health problems. Not knowing what to do and fearing for his safety, we took him to Sutter-Davis Emergency.
From there they called the mental health crisis official who apparently drives around the county in emergencies and provides some services. While he was a pleasant individual, the only service they would offer us was to basically commit our nephew and monitor him at their facility for a few days. We were not willing to do that.
We then started reaching out to the county, but nobody seemed to know what to do. Finally, we went to Supervisor Jim Provenza’s office, and his Deputy Gina Daleiden walked us across the hall to the Children’s Alliance, and Katie Villegas made two calls and got us into treatment. Eventually, the school district found out that they could get him educationally-based mental health services through his IEP (Individualized Educational Program).
The bottom line here: there are some services, most people do not know how to access them, and most people in the position of my family would not have the resources or the wherewithal to access them.
I recount this story as a prelude to the Grand Jury’s report which found the “need for better access to mental health crisis services in Yolo County.” Here’s the thing, we told this to at least three county supervisors three years ago, and it is not apparent that they acted on this information.
A press release came out this week on the Grand Jury’s findings.
They write that they “investigated a complaint that alleged the Yolo County Department of Alcohol, Drug and Mental Health (ADMH) did not provide prompt treatment to individuals experiencing a mental health crisis.”
ADMH is the county agency that provides treatment for alcohol, drug and mental health issues to the indigent and to Medi-Cal clients.
The Grand Jury found, “ADMH does provide treatment to people experiencing mental health crisis in its clinics, however, access and availability of treatment is limited by the location and operating hours of its clinics as well as a shortage of qualified mental health clinicians.”
They add, “Its clinics are located only in urban areas of Woodland, Davis and West Sacramento. The Woodland Clinic is only open 8-5 Monday – Friday and the Davis and West Sacramento Clinics are only open part time.”
The Grand Jury “learned that many people experiencing mental health crisis in Yolo County enter the treatment system through contact with law enforcement or referral to local emergency rooms. Law enforcement officers or a clinician may place a person experiencing mental health crisis on an ‘involuntary 5150 hold’ if the person is deemed to be a danger to himself, to others, or is gravely disabled. “
As we know, this itself is a problem, as law enforcement is often not the best trained or equipped to handle individuals suffering from mental illness.
Moreover, the problem is increasing as more people enter the system through law enforcement and 5150 calls.
The Grand Jury “examined data from Yolo County Sheriff’s Department, and from Woodland, Davis and West Sacramento Police Departments showing the number of ‘5150’ calls received between 2009 and 2012. In 2009, these four agencies responded to a total of 924 ‘5150’ calls; in 2012 the number of ‘5150’ calls escalated to 1471, an increase of almost 60%.”
“The Grand Jury called on all local law enforcement agencies to provide more of its officers with CIT (crisis intervention training) training and to develop an integrated plan to ensure that CIT trained officers are dispatched as first responders to ‘5150’ calls,” they add.
“The Grand Jury also learned that there is often a delay in receiving psychiatric care when a patient presents to an emergency room,” they write. “The patient first must be cleared of all non-psychiatric medical issues before being referred to a psychiatrist. Neither Sutter-Davis Hospital nor Woodland Hospital has a psychiatrist on site. Both hospitals contract for psychiatric emergency room assessments with treatment centers in Sacramento, further delaying access to care.”
This is what we learned in early 2011. The hospital had to call for service, we had to wait, and we were fortunate, as the individual on call came within the hour.
The Grand Jury “learned that ADMH recently received a $1.2 million grant from SB82 funds which are intended to assist counties to provide mental health crisis services. ADMH intends to use these funds to establish crisis response teams consisting of a licensed clinician and peer counselor who would respond, along with law enforcement, to a call involving a person in mental health crisis.”
They add, “These crisis response teams will be able to provide immediate treatment to the person in crisis, wherever they are located in Yolo County and at whatever time the crisis arises. It is hoped that these crisis response teams will reduce the number of individuals in crisis who seek emergency room treatment or who are arrested or taken to jail.”
This report confirms what we really knew back in 2011 and communicated to at least three members of the Board of Supervisors at that time. We understand that there are budgetary issues, but this is really becoming a crisis.
As we know in recent weeks, the mental health system has been in focus for its failure to deal with individuals that end up becoming dangerous to themselves and the community.
We are also concerned that, despite some very high profile cases that were mishandled by law enforcement, officials are not being properly trained in crisis intervention.
Hopefully this grand jury report will serve as a wake up call to the county that budgetary considerations have led to an alarming crisis in our mental health system.
—David M. Greenwald reporting
The Grand Jury “learned that ADMH recently received a $1.2 million grant from SB82 funds which are intended to assist counties to provide mental health crisis services. ADMH intends to use these funds to establish crisis response teams consisting of a licensed clinician and peer counselor who would respond, along with law enforcement, to a call involving a person in mental health crisis.”
David, are you aware of a county, similar in size and income to Yolo County, which has performed this function better and thus might serve as a role model for what our county should be doing?
The Grand Jury also notes, “The Grand Jury examined data from Yolo County Sheriff’s Department, and from Woodland, Davis and West Sacramento Police Departments showing the number of “5150” calls received between 2009 and 2012. In 2009, these four agencies responded to a total of 924 “5150” calls; in 2012 the number of “5150” calls escalated to 1471, an increase of almost 60%.”
I don’t know why the numbers of 5150 calls/admissions went up so much. It’s possible that it’s just a statistical blip or it has to do with some sort of crisis beyond law enforcement. One thing I know is that, in Davis at least, the police are hesitant to take someone in involuntarily. They will patiently try to get the person in mental health crisis to go to the hospital for an evaluation without force. It’s only after much effort and much waiting that they will order a 5150 hold.
The level of CIT (Crisis Intervention Training) among the county law enforcement agencies is quite variable with Davis topping out at 100% participation (thanks in part to Landy Black’s leadership) and almost zero percent from the Sheriff’s department. CIT is an evidenced-based practice that has shown great promise. That being said, having the SB82 funding is a great boost to crisis services, and the ADMH has also received funding for vehicles for the roving crisis teams. The county did an excellent job on the SB82 proposal, receiving the highest score of any applicant in the state. The new Director of ADMH – Karen Larsen – is a fresh presence in ADMH but is well known to many because she has been the director of behavioral health at CommuniCare for many years. We are lucky to have her.
Robert
Didn’t Suicide Prevention of Yolo County provide the mobile crisis unit service for many years?
SODA: Yes, they did but lost the contract a few years ago as part of the across-the-board cutting when the money dried up.
“David, are you aware of a county, similar in size and income to Yolo County, which has performed this function better and thus might serve as a role model for what our county should be doing? ”
I’m not, but it sounds like from what Robert says, we are moving in the right direction.
As a general rule in policy, I always think it makes sense to look at what comparable agencies are doing and what results they are getting, and, if possible, copy the policies of those who appear to be doing it right. This could be with mental health or any other government policy where your own performance is less it should be.
Along these lines–well, very far along these lines–I think it makes sense for poor countries whose development strategies are failing and have been failing for a long time to look to examples of countries with similar cultures and similar demographics for examples of policies which work. The best example of that is South Korea. Even though they hate the Japanese, the Koreans copied the Japanese development model and turned around a miserable third world economy into one which today is prosperous and first world. Taiwan, likewise, borrowed much of their model from Japan. And later (post-Mao) China largely copied what Taiwan did to move from poverty to wealth. … In Latin America, every country would do well to consider what Chile has done. It was the poorest of the large Latin countries in the mid-1970s, far behind Brazil, Mexico, Argentina, Venezuela, etc, in terms of economic growth and standard of living. By the early 1990s, it surpassed all those nations, and has mostly had a strong economy ever since, despite being ruled by a socialist party which undid some of the free-market reforms put in place by the Pinochet dictatorship.
Similar counties have 5150 facilities where a patient can be checked in voluntarily, or otherwise.
If the patient is quickly stabilized they can go home in a matter of a day or two.
Yolo County poured huge amounts of money into Safe Harbor Crisis House, but it has no doctor or RN or anyone qualified to prescribe meds, and it has an abysmal record of violations of licensing laws, and mistreatment of patients.
ADMH is riddled with problems from the simple and mundane on up. They cancel appointments without informing the patient or caretaker “because we’re too busy to make the phone call.” A patient with severe PTSD was told by the ADMH psychiatrist that the ONLY thing that would help is deep breathing and yoga –
and had no plan for even how the patient would access that sort of treatment.
The ADMH medical director is unable and unwilling to code lab work so insurance will pay the cost. His nurse explained that the doctor doesn’t know and doesn’t care whether the indigent or MediCal patient has to pay the
$200 + cost of lab work each time lab work is ordered. Another doctor prescribed a medication, but it took WEEKS of reminders to get anyone at ADMH to write the prescription in order for the pharmacy to fill the prescription.
ADMH staff generally are very uncaring of their patients.
ADMH management explained that in fact they don’t know whether their doctors are at work in the bldg., or whether they’re out having fun. This was the answer to my inquiry as to why one of the doctors was spending his afternoons at the gym in Davis. “We evaluate our doctors on how many chart changes they make.” Chart changes are billed to Medi-Cal and generate income, whether they do the patient any good at all. The medical director at ADMH makes chart changes for patients he’s never seen or talked to at all. He picks up a chart and changes the time meds are to be given, or orders labs that aren’t needed, to the patient’s detriment, in order to run up a bill to the state.
New Mexico’s county clinics were recently caught doing the same thing and owe the state staggering amounts of repayments, millions of dollars.
It’s important to recognize that Response Teams can’t do anything to treat a patient in crisis, i.e., a “licensed clinician” is simply a social worker who cannot prescribe medications. Apparently the response team would try to calm the patient and arrange transport to a hospital with psych. beds. (Woodland Hospital has had the practice of leaving psych patients in the ER for 12 hours or so without any of their prescribed meds being given, and then as the patient gets worse, the patient is moved upstairs to fill a bed in their psych unit, where almost half the patients don’t have a doctor at all, let alone a psychiatrist, they’ve had a “doctor” who is actually a physicians assistant. How many patients knew that “Dr. Ben” wasn’t a doctor at all! And he was assigned to the most severely ill patients who wouldn’t figure out that he wasn’t a doctor.)
Thank goodness for Karen Larsen, she’s going to have a long term and deep mess to clean up at ADMH.
“Thank goodness for Karen Larsen, she’s going to have a long term and deep mess to clean up at ADMH.”
TJ, so am I right to conclude that you believe the problems are with ADMH management, and a new person running the department could resolve the issues you say exist?
A second question has to do with the Board of Supervisors: Do you know if they share your beliefs about the management situation at ADMH? And if so, have they had any input on reforms there?
Rich, Yes, I do believe there are serious problems with ADMH management. The idea that it’s okay that taxpayer-paid employees, i.e., ADMH doctors, are not even working during their 8 to 5 work day schedule, leads to various problems. How do other staff feel about putting in a hard and strenuous day while a doctor is recreating on county time at the gym?
With ADMH’s focus on chart changes, there’s less focus on actually treating the patients, and I listened to former director Kim Suderman brush off the idea at an LMHB meeting that ADMH should track not just successes, but also failures in patient care, so that improvements could be make.
It must be discouraging for doctors to work with management when they are judged by
how many billings they generate, rather than their success with patient care.
I’ve talked to Provenze and his staff many times and it’s just a quiet brick wall. No interest in patient care at all that I can detect. Likewise Saylor.
My impression is that if ADMH management does what they want, like cut off funding for Families First, before CCL concluded its investigation, or pours money into a favorite agency that will promise some kind of election support, then these politicians are happy.
Rexroad expressed some concerns publicly about combining Employment & Social Services with ADMH and the Health Dept. I think his concerns are well taken.
You can pour all the money in the world into ADMH, but it wont’ be effective unless good dedicated staff are interested in quality patient care, AND staff has the full support of management in providing good care.
Yes, I think Karen Larsen can and will make improvements even with limited funds, but I would expect it to take some time to change the present culture, and, especially, hold the doctors to a higher standard of competency.
(I will say that there are some excellent staff at ADMH but I also know they find it very discouraging to see their efforts undone by one management mistake or another, time after time.)
tj I would appreciate it if you brought the problems you know of either to the Local Mental Health Board’s attention or directly to Karen. If these situations (particularly the ADMH employees) then she needs to know and the LMHB can be a conduit. The members of the LMHB are listed on the county’s web page at: http://www.yolocounty.org/health-human-services/alcohol-drug-and-mental-health-/local-mental-health-board-
You can email directly to the Board of Supervisors (Saylor is the main LMHB liaison) or to Bob Schelene who is the chair of the LMHB or Karen Larsen.
Re. 5150 beds, Yolo is not alone in this problem. Many counties have zero beds available for crisis patients. Although services are difficult to access at times, we are lucky to have Woodland Memorial’s beds in the county. The county also uses Heritage Oaks and Sierra Vista when needed for 5150 patients.
RC,
I appreciate your suggestions.
I would like to point out however that many or most of the people on the LMHB have vested interests, i.e., they are providers that depend on ADMH.
Saylor and Schelene, in my experience, are more interested in protecting ADMH management than in doing anything constructive.
Although there have been terrible problems with pysch care at Woodland, in recent months they told me that they have made some improvements, gotten rid of the fake “doctor” Ben, and changed the company they contract with which provides the doctors and PA’s in the psych unit.
E.i., Woodland Hospital basically rents out 3-B North to a private company. The hospital claims to have contracted with a better company than in the past.
I’m not aware of any improvements in their ER, which is really a shame. Psych patients are treated very badly at Woodland Hospital.
tj: As far as I know no LMHB board members are providers of services with contracts with the ADMH. Not sure where you have gotten your information. In fact, I believe that there are only two licensed mental health providers on the panel – myself and one other. I work for the prison system and the other member is a lobbyist in Sacramento.
I will be very interested to see how changing access to health care in general and access to mental health care in particular as individuals take advantage of insurance for the first time due to the ACA related exchanges.
In my field, we have seen a marked increase in the number of new patients. Prior to January of this year, I had what is considered a “mature practice” with most of my patient’s already women established with me and a few patient’s not new to Kaiser, but new to me since they were university students or 18 year olds graduating from pediatric to adult care. Now, I am averaging about two to four new patients daily and my partners seem to be getting about the same.
If this also holds true for the FP and Internal Medicine practitioners, we can look forward to large increases in patients needing mental health services. How this plays out across the county as some patients who previously had no access to care except through CommuniCAre / ER/ or 5150 will now be taxing the resources of the private providers as well. For Kaiser, the majority of these patients are taken care of in either Vacaville or Sacramento and thus are not necessarily captured in the county statistics, but may still present local challenges to mental health crisis providers.
If mechanics understood cars as well as our local government understands the mentally ill in Yolo County, then dealing with car problems might work like this:
After having cut apart and ground up thousands of working and non-working cars, mechanics would know that a lack of gasoline, oil, or water was a common factor in many common car failures. Thus, whenever a broken car was brought into their shop, they’d pop open the hood and pour a bucket of gasoline, oil, or water over everything (depending on the symptoms) to try and fix the problem.
Creating crisis response teams is a great start but it is a reactive, feel good approach. The only people that will be helped are the politicians in the making of political ads for themselves.
If we truly want to fix this problem we need a proactive approach in a very big way. In my opinion every mental health worker and every social worker in the county should move away from their little desks and start their shifts at the largest mental health facility we have, the Yolo County Jail.
Clem, I hate to disagree with you but by the time someone gets to the jail, it’s too late. The proactive approach is to divert people from the criminal justice system in the first place. We have been without any kind of mobile crisis teams for a number of years. The police are the typical first-responders when someone is in mental health crisis and is not taken by friends or family to an emergency room (there to wait for a long time for a mental health professional to see them). Why not get to them before or with the police so maybe we can get them diverted. Although the jails and prisons have become de facto mental health treatment facilities, it would be better to keep the folks who need the help out of them in the first place. Getting our county’s crisis response teams funded is a good step in the right direction.