.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.

Children’s advocate Kathleen “Kathi” McLaughlin addressed the Contra Costa County Board of Supervisors last summer about an ongoing issue that the county has kept largely hidden, the poor and dangerous conditions for children and adolescents at the county’s emergency psych ward.

McLaughlin, a Martinez school board member and former Mental Health Commissioner, recounted a story about a suicidal 14-year-old girl who sought emergency treatment at the facility. She and her mother waited hours at the grim, outdoor waiting area, which is immediately adjacent to a busy roadway. When the teenage girl was finally admitted the following day, a nurse took her to an exam room to check her heart rate. Just as the nurse lifted the girl’s shirt, a male patient who had been committed to the facility on an involuntary psychiatric hold barged into the examination room.

“That would be hard for an adult, for a 14-year-old girl, it’s really hard,” said McLaughlin who has advocated for change at the facility for years.

The Board of Supervisors had just been served with a grand jury report that for a second time outlined problems at the facility, which is known by its oddly truncated name, Psychiatric Emergency Services (PES). The scathing report contained no new information for the supervisors, who have been aware for years of the serious issues at PES: overcrowding, chaos, violence, staffing shortages, little to no access for families, patients regularly sleeping on the hallway floors, and emotionally vulnerable children sharing hallways and waiting areas with volatile adults.

“This report is an opportunity to actually do something about PES,” McLaughlin told the board.

What the grand jury report did not note is that Psychiatric Emergency Services has seen a 68 percent rise in aggressive incidents including physical violence and property damage during 2019. And aggression among youth in the facility has more than doubled. Most worrisome for children and adolescents is that the violence, including kicking, punching, hair-pulling, and throwing heavy objects, occurs suddenly in common areas, like hallways, that children and teens regularly share with adults who have been placed in the facility on an involuntary psychiatric hold because they present a danger to themselves or others.  

There has been no investigation into the sudden rise in aggression, but hospital officials suggest the increase is due to more aggressive acts by minors and overlong detentions of minors who, by law, should not be confined for more than 23 hours. In some cases, according to the report, they are kept for five and six days. But advocates such as McLaughlin claim the problem is due to overcrowded conditions and minors being forced to stay in windowless, confined areas in an outdated building for days without proper treatment for their conditions.

“It’s illegal and inappropriate to keep children and adolescents in an emergency psychiatric facility for more than 23 hours,” McLaughlin said. “They are meant to be stabilized, assessed and then, if necessary, sent on to a long-term inpatient facility or released to caretakers for outpatient treatment.”

The conditions McLaughlin described were not missed by the grand jury. Psychiatric Emergency Services saw a monthly average of 848 patients during 2018, according to the report. Almost 16 percent of those patients, or an average of 134 per month, were children 7 to 12 or adolescents 13 to 17.  

There are only four “beds” for minors at Psychiatric Emergency Services, but the beds are really reclining chairs crammed, two each, into two very small rooms. When there are fewer beds than children, they are given mats to sleep on the floor.

The hidden factor of these poor conditions is the psychological impact on vulnerable and agitated youth who are confined in an overcrowded, chaotic environment of spit guards, restraints and narcotic stares.  

“Upon arrival at PES, and when they leave, children and adolescents must pass through the adult area to reach the assessment rooms,” the report said. “Distressed children and adolescents are exposed to adult patients needing psychiatric help. PES staff state this could cause additional trauma to the children and adolescents.”

In fact, Psychiatric Emergency Services has become so dysfunctional that at least two staff members regularly and openly warn people to NOT allow their children and teens to be checked into the facility, according to county mental health workers.

Ange Cottone, a registered nurse and union rep for the California Nurses Association, said violence is a problem at Psychiatric Emergency Services and other county hospital departments. “Contra Costa County is required by state law to produce a workplace violence-prevention plan,” Cottone said. “We are overwhelmingly disappointed that the county has lingered with a deficient plan and they have neglected any input from frontline employees. They have left hospitals, clinics, detention facilities, and offices unsafe for both staff and patients.”

The lack of attention to these issues also lies with the Contra Costa County Board of Supervisors. The grand jury report chided supervisors for not addressing the hospital’s problems , which have been neglected for years. “The Contra Costa Mental Health Commission recommended changes to PES to improve treatment space for children and adolescents,” the report reads. “The grand jury did not find any evidence that the commission’s recommendations had been implemented.”  

McLaughlin said she has been frustrated trying to get supervisors and hospital administrators to take action regarding Psychiatric Emergency Services and that many other activists who had over the years worked hard to create change at the facility have simply given up — just like the supervisors. “At one time, the Board of Supervisors was interested in fixing this problem,” McLaughlin said, “but it seems like they’ve given up for some reason.”

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.

But the conditions at Psychiatric Emergency Services suggest that there has been a stagnation in Contra Costa’s mental-health services. The grand jury report and other documents and emails obtained by the Express demonstrate that agency administrators have misrepresented the facts, cited vague and obstructive regulations for expediency, withheld data about controversial and dangerous treatment practices such as mechanical restraint, and targeted certain employees for retaliation.

While the problems at Psychiatric Emergency Services seem intractable, the documents suggest they are primarily the work of one administrator, Chief Operation Officer and Chief Financial Officer Patrick Godley, an accountant with no medical or mental-health training, who has nixed all nascent proposals to remove minors from Psychiatric Emergency Services.

Psychiatric Emergency Services was originally designed to hold 14 to 20 patients per day. It now holds double that amount on a regular basis, according to a 2017 white paper report jointly prepared by the Mental Health Commission in tandem with Behavioral Health Services. And the number of patients who visit Psychiatric Emergency Services annually is steadily increasing.

From 2007 to 2010, the median number of patients was 6,727. But between 2014 and 2019, the median has increased to 10,511 patients. Annual patient volume has leveled off the past few years, but with patient sleeping on the floor and children and adolescents staying longer than the legal 23 hours, the building has little to no room to grow.

There is some evidence of correlation between overcrowding and the increase of aggressive acts including physical violence. During 2019, there was a high of 764 adult patients and 64 youth patients during April. That elevated attendance coincided with 12 incidents of youth aggression, the highest for the year, according to Behavioral Health Services numbers.

Dr. Zeller, who now consults hospitals on the development of crisis stabilization units for the Emeryville-based medical company Vituity, said it’s very difficult to raise quality of care for psych patients because they are typically a low priority on most hospital campuses. Psychiatric trauma is not obvious, there’s no blood, no broken bones and you can’t see the conditions in an X-ray, Zeller said. “For many people, just putting these patients away somewhere is enough.”

Furthermore, he noted, psychiatric patients and their families are typically not likely to show up at supervisors’ meetings and medical committees to lobby for improved services, which adds to their anonymity and makes it easier for hospital administrators to ignore bad conditions and substandard treatment.  

In 2015, an opportunity presented itself to ease the pressure on Psychiatric Emergency Services. A wing of the hospital known as “4-D” was vacant. It seemed to advocates like a good opportunity to improve the conditions for patients at the facility. The wing was used as a locked psych ward at one time, and it had been unused for years. A group of stakeholders led by Vern Wallace, then the chief of the hospital’s Behavioral Health Child and Adolescent Program, began putting together a plan to resurrect 4-D as a 10 or 20-bed inpatient unit for youth.

“We were all excited about the prospect of opening an inpatient facility in 4-D,” McLaughlin said. “Vern felt like he had the support of the administration and he worked with children’s advocates, mental-health advocates, hospital staff, the various committees. It looked good.” 

The first step of the plan was to conduct a financial feasibility study, which was undertaken by Wallace, a highly respected county employee who had most recently overseen the development of the Children’s Mental Health Clinic in Antioch. Wallace did exhaustive research on the daily cost of beds, average length of stays in the state, cost of salaries and benefits to run the unit on a 24/7 basis, plans for healthful activities such as art classes, and even a meal schedule. His financial forecast was quite rosy.

According to his data, start-up costs such as retrofitting, supplies, and durable goods would have been paid for through the Mental Health Services Act. Consequently, he believed, the facility would actually have saved the county a good deal of money, provided that any excess beds that weren’t being used were leased out to nearby counties also experiencing an acute shortage of inpatient beds. Wallace had also generated interest in dedicated beds from the counties of San Francisco, San Mateo, Alameda and Marin as well as Kaiser Hospital. He estimated that full occupancy would have saved the county $1,719,350, including the money saved from farming out county patients to other counties, where patients are isolated and family members often have difficulty visiting or participating in family meetings with doctors and nurses. But even at just 85 percent capacity, he projected that the county would have saved money.

But  Patrick Godley immediately killed the report, buried it without any written analysis and little comment. Then, according to a series of emails obtained by the Express, Godley put a plan in motion to undermine Wallace and “side line him.”

Coming next week: Part Two — The influence of Patrick Godley


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