One county drops a service and another county picks up the slack. It’s happening between Fresno and Kern counties when it comes to care for mentally ill patients in crisis.

Two years ago, Fresno County shut down its mental health crisis stabilization unit, blaming high operating costs. Patients released after the closure ended up back in the hospital – this time in the ER under an involuntary medical hold. Fresno emergency rooms were ill-equipped to handle mental health issues, and hospitals shipped them off to Kern County for psychiatric crisis treatment.

That arrangement doesn’t sit well with Kern County officials, who say the eagerness of Good Samaritan, a Bakersfield hospital, to gain business from Fresno resulted in a drain on county funds because of court hearing costs.

“If (another county) wants to hospitalize someone here, then, in my opinion, they need to bring the person here, participate in treatment planning, pick up the person and have an appointment available for them when they get back,” said Jim Waterman, director of Kern County Mental Health.

The Kern County Board of Supervisors responded in May by removing Good Samaritan Hospital’s ability to take adult patients on involuntary holds. Now the hospital has come under scrutiny for allegations of poor reporting procedures and patients’ rights violations.

Inundated with involuntary holds

Police and certain medical professionals can place an individual on an involuntary hold of up to 72 hours when he or she is considered suicidal or a danger to others. The term 5150 refers to the corresponding citation for the hold in the state welfare and institutions code.

Donna Taylor, director of the Fresno County Department of Behavioral Health, said the decision to close the crisis unit in July 2009 relied on figures that did not accurately reflect the volume of 5150 patients. Patients have continued to inundate Fresno County emergency rooms in high numbers, some 500 to 600 per month, Taylor said.

Fresno County is on track to reopen a crisis stabilization unit in November or December. Taylor is confident the unit will be ready on time, despite the economic downturn, and at a pricetag near $4 million. The privately operated center will provide 12 beds, with a focus on timely stabilization and links to support services. Although it won’t resolve the problem entirely, Taylor said, it will provide relief to local emergency departments.

“If we don’t have good follow-up care, it doesn’t matter what we do in crisis,” she said. “They will continue to come.”

Stressed in the ER

Emergency departments often don’t have the time, resources or mental health staff to handle high volumes of psychiatric patients. Police sometimes add to the problem by applying 5150 holds in less dangerous cases. For example, a threatening comment by a person under the influence of drugs or alcohol might result in a 5150, but that comment could have been an idle threat. Taylor says her department is educating law enforcement on making more informed decisions about detainment.

Before July 2009, the emergency department at Saint Agnes Medical Center in Fresno saw about 30 involuntary hold patients per month. That number jumped to between 120 and 130 patients monthly after the county’s crisis unit closed, said Dr. Richard Winters, hospital president and emergency department chairman. Each patient remained in the department around 16 hours before leaving the hospital.

Those numbers haven’t changed much. On any given day, the Saint Agnes emergency department still sees four or five involuntary hold patients, Winters said. And the expenses of hiring security guards, a social worker, adding nursing shifts, and similar needs add up.

When a 5150 patient comes to the hospital’s emergency department, the individual is placed in an isolated area with a security guard. Physical injuries are treated, and medical staff and a social worker evaluate the patient to determine if he or she poses a safety threat. If the hold stays in place, the patient is sent by ambulance to the nearest psychiatric unit.

The biggest obstacle is finding room for patients in psychiatric treatment centers. That 16-hour wait time for a psychiatric patient in the emergency department delays treatment for people suffering from pneumonia, fractures and lesser traumatic emergencies.

“The average patient, we’re able to take care of in four hours, some are less than that,” Winters said. “So every psychiatric patient we’re holding, there are four patients we could be seeing in that amount of time. And there’s a shortage of beds in emergency departments in the Valley in general.”

The loss of Good Samaritan’s services hasn’t resulted in a noticeable increase in patients at Saint Agnes, Winters said.

“On the other hand, I know that the closure of Good Sam to our 5150 patients is certainly going to hurt us, just as the closure of a trauma center would hurt outlying counties,” he added.

Saint Agnes doesn’t have a psychiatrist in the emergency department, but the problem has led the hospital to add a social worker for 5150 patients. It’s become a personnel safety issue, so the hospital has hired security guards. In the last three months, three Saint Agnes emergency department employees were kicked and punched by 5150 patients, Winters said. They suffered minor injuries.

“It’s a risk of the job now,” he added.

Who foots the bill?

Kern County entered into the contract with Good Samaritan to serve adult involuntary patients in 2007. The hospital continues to serve minors and voluntary adults. Kern County has paid for costs associated with required court hearings to determine if these out-of-county patients should remain committed. The county pays for hearing officers, patients’ rights advocates, county counsel, and public defenders, said county mental health director Waterman.

He noticed the change after Fresno’s crisis unit shut down. Last year, from January to August, 52 percent of clients at Good Samaritan were from Fresno County, compared to 22 percent from Kern County.

Waterman and Taylor have discussed potential solutions. Waterman wants to create an inter-county agreement so that other counties pay for the services their residents use. Taylor has reservations. Her department foots the bill for the smaller counties of Kings and Madera. They rely on Fresno County’s psychiatric resources, she added, although their patient volumes are small and conservatorship costs are borne by the patient’s home county.

“Part of me says, ‘Are we going to set precedent that we’re going to start billing every county for all these other things?’” Taylor added.

Taylor also said she has no control over where emergency rooms send their patients.

“We’ve always told the emergency rooms, our preference is to stay local,” Taylor said. “However, I do understand that from an emergency department (perspective), this client is sitting there eating resources and they need to move them, and if the facilities locally will not respond quickly, they will do whatever to move them where they need to be.”

Quality of care

Kern County officials also want intensive monitoring of safety issues at Good Samaritan and an agreement that the hospital will take only clients from counties that have an inter-county agreement. Waterman said it will be months before plans between Kern and Fresno counties take hold.

Both county mental health directors are concerned about Good Samaritan’s quality of care. Waterman said the hospital does not properly self-report to the county and hasn’t worked with the county to address problems. Kern County patients’ rights advocates reported the hospital had inadequate discharge plans for patients to receive appropriate support back home. And the county claims hospital officials were poorly prepared and provided inadequate information at court hearings.

According to the advocates’ reports, in July 2010, a man was discharged and placed on a Greyhound bus rather than a hospital vehicle. He held the bus hostage at gunpoint in Tulare County and was arrested. And in September 2009, a Fresno County man released at midnight with no discharge plan was assaulted shortly after release, re-hospitalized and placed on a mental health conservatorship – one of the county’s most expensive services – at a cost of $65,000.

Acharya of Good Samaritan wouldn’t comment directly on allegations, but he said the hospital is accredited and in compliance with state licensing. He added that the hospital takes initiative to correct problems and has a peer review process that handles allegations against physicians. The hospital is also working on improving self-reporting with Kern County, although it already reports to the state. Discharge plans are formulated from the time a patient walks in the door, including housing and transportation arrangements, he added.

Waterman said it’s more cost-effective to provide patients strong outpatient care with regular check-ups that keep them stable.

“What if we were getting 90 diabetics a month coming down to go to an intensive care unit in Kern County?” Waterman added. “Then when they were stable again, (we) put them in a van and took them back to Fresno and released them on the street until they had another diabetic crisis and went to intensive care in Kern County? Taxpayers would go ballistic.”

Saint Agnes previously sent patients to Good Samaritan, and continues to send them to Community Behavioral Health Center in Fresno, plus Kaweah Delta Health Care District in Visalia, among others. Winters said his first priority is to send patients to Fresno County psychiatric facilities.

Hospitals have trained emergency department staff on how to handle 5150 patients, Winters added. Beds in Fresno County substance abuse detoxification units have been made available in recent months, providing some relief. And Fresno County hospitals want to create a shared database that would track 5150 patients and flag repeat visitors. The goal is to help health care workers create more comprehensive, coordinated treatment plans for patients who cycle in and out of the system and drain resources.