California is sending far too many kids with mental health issues to hospital emergency rooms, driving up costs, adding to their trauma and contributing to high rates of youth suicide, experts say.
Despite available resources and models from other states for creating a system to treat children in their homes or the community, most California counties are ill-equipped to handle kids in crisis.
Forty-four of the state’s 58 counties do not even have psychiatric hospital beds for children and adolescents in mental health crisis. But far more troubling is the lack of programs to keep them from escalating to that point.
But there is hope: a handful of counties are developing mobile crisis teams and 23-hour crisis stabilization units where youth can be helped at home or in calm settings without forcing families to resort to law enforcement, ambulance rides to emergency rooms and long waits for psychiatric hospital beds far from home.
More than half of children seeking help in emergency rooms, which are usually unequipped to treat them, will go home without any mental health evaluation. They end up further traumatized and without services, reports Kids in Crisis: California’s Failure to Provide Appropriate Services for Youth Experiencing a Mental Health Crisis, sponsored by the California chapter of the National Alliance on Mental Illness and other advocacy organizations.
Lisa, (not her real name) a Santa Cruz County resident, noticed that her youngest daughter was different than her three sisters. As a toddler she had terrible temper tantrums and was highly needy. Despite expensive psychiatric visits for seven years Lisa had to quit her teaching job when her daughter left school in the 6th grade, showing signs of autism and unable to cope.
Last year things really started spiraling out of control and she had to call the Sheriff at least nine times because her daughter, now 15, became violent with the family and herself.
“We have no mobile response teams, in our county you have to call the police or 911. They handcuffed her and took her away, it was horrific,” Lisa said. It’s so traumatic, the whole family has nightmares, she said.
“When law enforcement is your mental health support line, we’re making a systematic error,” said Ken Berrick, founder and CEO of Seneca Family of Agencies, a nonprofit providing services in mental health, child welfare, education and juvenile justice systems.
Berrick said calling law enforcement, transporting kids to emergency rooms via ambulances where they wait for up to two days for hospital beds in psychiatric hospitals 25 to 100 miles from home is ineffective and traumatizing. And the cost to the child’s family and the system skyrockets.
An average emergency room visit costs $2,000 and an ambulance transport in Los Angeles County is $1,000, according to the Kids in Crisis report.
“I think there needs to be legislative change. We’re creating our own crisis,” Berrick said.
Some counties are finding ways to do things differently. Seneca runs the Willow Rock Center, a crisis stabilization unit in San Leandro founded with Alameda County in 2008. It receives youth 12 to 17 in acute crisis, assesses between 1,500 and 1,600 annually and diverts about 50 percent of them from hospitalization.
Kids often arrive by ambulance. Nurses, psychiatrists and therapists assess them emotionally and physically and kids stay up to 24 hours.
Willow Rock has 10 tastefully decorated rooms with sofa beds and kitchens and peaceful spaces for family to talk, meet with therapists and construct safety plans with the child.
Last year Santa Clara County opened a similar facility. The County also has a 20-year-old mobile crisis response team which diverts 70 percent of kids in crisis from going to the hospital, said Margaret Ledesma, Children’s Crisis Services Manager for the Santa Clara County Mental Health Department.
While counties like Contra Costa, San Diego, Santa Barbara, Ventura, Sacramento and recently Santa Cruz, have implemented mobile crisis teams and other services, no California county has a full continuum of care for kids in crisis.
Ideally that continuum would consist of mobile crisis response teams stabilizing children at home or school and likely diverting 50 to 70 percent of them from hospitalization, Berrick said.
If a child needed more help they’d go to a 23-hour crisis stabilization unit like Willow Rock where 50 to 60 percent of those kids could get help and go home.
If it’s still not safe for the child to return home, Alameda County youth can be taken from Willow Rock next door to the Telecare Corp., a psychiatric health facility where they can stay longer.
Having those steps on the front end of the continuum dramatically reduces the number of psychiatric hospital beds you need, Berrick said.
“Then you really know who’s in trouble.”
Debra, (not her real name) a single mom in Santa Cruz County, has a 16-year-old daughter who has been dealing with mental health issues since preschool. Debra wasn’t able to find resources in Santa Cruz to help keep her daughter at home. For the last four and a half years she has lived in four residential treatment programs in New Mexico, Oregon, Houston and Utah for between $6,000 and $10,000 per month.
“It’s a racket, it’s really really sad, it needs to be federally regulated,” Debra said.
Lisa’s family has also borne that financial burden. For seven years they paid a Los Gatos psychiatrist, who doesn’t take insurance, $415 per session. Last year the family’s finances changed dramatically and they had to switch their daughter to Medi-Cal.
After stays in psychiatric hospitals in San Francisco, Fremont and Sacramento, hospitals stopped accepting her. Lisa had to find a pro bono attorney, sue her school district and get it to pay for a residential facility in Utah where her daughter is now. The school district decides when she’s well enough to come home.
Only 29 providers of inpatient adolescent psychiatric services exist in the state, and only 11 of them serve children 11 and younger, reported the California Hospital Association (CHA) in August.
“Insured or not, wealthy or indigent, access to services for California children is extremely limited and in many cases unavailable,” CHA stated.
One effort to provide more children’s crisis residential facilities, which are less restrictive than hospitalization, is Assemblyman Das Williams’ bill AB 741. He proposes creating a licensing category for billing Medi-Cal to help counties pay for these facilities and access federal matching funds.
What alarms Williams is the high rate of child suicide. The Centers for Disease Control reported in March that for youth aged 10 to 24 suicide is the third leading cause of death.
“If children are housed in emergency rooms or shipped off hundreds of miles from home it decreases our chances of intervening early enough to prevent a second attempt,” he said.
While AB 741 would probably help, said Toby Ewing, Executive Director of California’s Mental Health Services Oversight and Accountability Commission, theoretically funds already exist to create these services.
“The goal is that between private insurance, Medi-Cal, Affordable Care Act coverage and MHSA [Mental Health Services Act] we should be able to provide a full array of services that children need. But we’re not there yet,” Ewing said.
So families like Debra’s are forced to place their kids in other states too far away to participate in the treatment that could help safely transition their children back home.
Currently Debra’s daughter lives in a residential facility in Utah paid for by her school district.
“She’s had to live away from home for four and half years,” Debra said. “It’s tragic for both of us. It’s really hard to let other people raise your child.”
While the recession limited the county’s ability to serve these children said Giang Nguyen, Santa Cruz County Health Services Agency Director, the county is starting to turn things around. It launched a mobile crisis team in July, a new behavioral health center with a children’s crisis intervention program a couple of years ago and recently an on-site psychologist was hired to assess patients at Dominican Hospital’s emergency room.
The County and the Central Coast Alliance for Health, a nonprofit health plan serving residents of Santa Cruz, Monterey and Merced counties covered by Medi-Cal, have also created a memorandum of understanding to cooperate in providing clients appropriate levels of care.
Despite huge gaps in care across the state, many agree that the tools and resources for a solution already exist. Money is available to create services, good models exist nationwide, and communities have incentives for taking children out of emergency rooms and ambulances and putting them in the hands of people who can help them locally.
“We understand the problem and the solution,” Berrick said. “It’s just a matter of organizing the system.”