Hillcrest Hospital’s Cut in Beds Brings Problem Into Open

Patients who would have been admitted to San Diego County’s Hillcrest mental hospital a year ago are now being shuffled among other hospitals and mental-health providers less well-equipped to handle such cases.

Some of these patients are being turned out on the street with little or no treatment, some mental health officials say.

The patients, many of them violent and most of them without money or private or government health insurance, are being treated differently as a result of the Hillcrest hospital’s decision to eliminate one-third of its 92 beds and treat each patient for longer than before.

Combined, the two policy changes mean that Hillcrest, San Diego’s largest (and only public) hospital for the severely mentally ill, is now admitting only about half as many patients as it did a year ago. The director of one hospital emergency room said psychiatrists there sometimes are reluctant to send suicidal or homicidal patients to the county for fear that the patients will be turned away or released without adequate treatment.

But county officials say those patients who get into Hillcrest today receive far better care than when the hospital had more beds. The officials say that the county’s sickest people are still granted admission but that many persons who traditionally have come to their doors can and should be treated without admission or referred to other, less restrictive, medical facilities.

County officials argue that the underlying problem is a lack of public funds for the mental health care system, a situation they alone cannot solve.

The reduction in beds--from 92 to 60--was a key move last year in county efforts to improve the level of treatment at the troubled acute-care hospital by decreasing the number of patients seen by psychiatrists and increasing the number of days the patients remain hospitalized. The beds were cut after several hospital psychiatrists quit and Hillcrest officials were unable to recruit enough replacements--leaving the facility with just three full-time doctors.

At the time, the county had been under intense criticism by state and federal health officials for substandard care, and early this year the federal government revoked the hospital’s eligibility for Medicare funds because of those problems.

But the bed-cut solution has unleashed strong criticism from other mental health providers in the county.

“It’s as if a poor husband and wife with five children, all malnourished, shoot three of the kids to help feed the other two a little better,” Dr. David L. Braff, director of inpatient psychiatric services at the UC San Diego Medical Center, which is next to the Hillcrest hospital (also known as CMH).

“Even when CMH had 92 beds, that was probably too low for a county this size,” Braff said. “But now what they have done is disperse the problem into the community.

“We have a total mental health disaster because the system is underfunded and inadequate in the number of people to be treated.”

Under agreements with safety and medical officials countywide, Hillcrest takes patients with mental health problems who do not qualify for government or private insurance; it also evaluates all emergency patients who appear to have mental problems. Once evaluated in the Hillcrest emergency room, these patients are either admitted, treated and released, sent to other hospitals that contract with the county or, if they have the means, referred to a private hospital.

Until last summer, Hillcrest automatically took all indigent patients on referral who went to UCSD or other hospital emergency rooms and appeared to have mental problems. If CMH were full and received a particularly serious patient, a less seriously ill person was discharged to make room. Now Hillcrest tells private hospitals to hold those patients in their own emergency rooms until CMH has time to see them.

As a result, the patients--often loud, aggressive and difficult to handle--must either be released or kept in emergency rooms for several hours until Hillcrest can accept them for evaluation, though with less assurance than before that they will then be hospitalized.

The emergency rooms at UCSD and Mercy Hospital have borne the brunt of the change, officials say. UCSD, so close to the Hillcrest facility, treats the county’s physically ill indigents and serves mentally ill patients who have government insurance such as Medicare and Medi-Cal. Mercy, about half a mile from UCSD, provides a full range of medical services to private and government-subsidized patients.

“The homeless wander down the street and often end up at Mercy,” said Dr. Lawrence C. Thum, medical director of Mercy’s mental health unit. “Before, we would find it quite easy to get this type of violent patient transferred to CMH, traditionally the single place within the community to take care of such people.

“Now CMH literally is just stonewalling us, often not taking anyone for evaluation when we call them. So our emergency room has a real problem with what to do, since some of these people are in such terrible shape that you can’t put them back on the street.”

Both Thum and Braff said the patients disrupt normal emergency room procedures because the facilities are not equipped to deal with violent and abusive mentally ill patients.

“You try to put these patients in rooms with doors but you don’t have that many,” said Terry Santa Maria, a nursing supervisor in the emergency room at Mercy. “Other patients sometimes get very upset with these abusive people around. And here we are trying to keep them for four, five, six hours during the night while we’re on the phone trying to get them over to CMH or into some other facility and at the same time handling another patient with chest pains in between phone calls.”

The Emergency Room Nurses Assn. of San Diego is drafting a letter to the county Board of Supervisors about the problem after hearing complaints from several nurses at UCSD and Mercy.

“More and more, these people are in our emergency rooms for up to three days (the maximum time they can be held on an emergency basis under law) since we believe we can’t risk both society and patient by letting the person go, or by having them go over to CMH and be discharged (without treatment),” said Barbara Parry, director of emergency psychiatric services at UCSD Medical Center.

“Those patients that we deem suicidal or homicidal and we think should be hospitalized, CMH will let go, so we don’t feel confident in sending them over without a commitment from CMH to hospitalize. But the emergency room with all its trauma and commotion is the worst place to try and stabilize these people.

“If we’re not sure of what patients will do if we release them, we keep them even though our administration says don’t” because of the cost.

The cost issue is an additional problem for Mercy and UCSD because the county will not reimburse those hospitals for treating the indigent mentally ill in cases where they are not under CMH care.

“In essence, we just practice charity,” Thum said. Santa Maria said that when she calls community hospitals with psychiatric units to try to place patients from Mercy’s emergency room, the first question is, “ ‘Do they have insurance?’ Everyone is reluctant to take these people.”

Although Mercy has a nine-bed locked unit, Thum said it usually is filled with non-indigent patients. “When we admit an indigent patient because we can’t get them in CMH and feel an obligation, it causes problems with the families of other patients, who take one look at someone with lice, or who may smell terrible, and pull their (full-paying) patient out.

“You just can’t mix all types of patients. CMH traditionally has specialized in the worst psychopathology.”

The San Diego Police Department has begun keeping statistics on the number of mentally ill persons that officers take to Hillcrest on “5150s,” the provision of state law that allows police to arrest a person who appears to be acting in a way dangerous to himself or others. Lt. Bill Skinner of the field operations division said that patrol officers in recent months have expressed “frustration and concern” that people they take to Hillcrest are not being hospitalized.

“We are now trying to back up that concern by compiling statistics to see if that is the case,” Skinner said. “I can’t say this is a major problem because we have no statistics now; it’s more impressionistic at this point.”

Skinner said CMH officials have told police that the reduction in beds has resulted in fewer persons being admitted for treatment.

One recent example: Police last week took a 21-year-old man to Hillcrest for evaluation after having talked the man out of wielding a 10-inch butcher knife and making verbal threats in his parents’ house.

“But the officer (in his official arrest report) says the evaluating doctor said that CMH could not take the man because no beds were available,” Skinner said. “The doctor wrote, ‘Patient evaluated, no beds available, released back to police.’ So we booked him on a misdemeanor charge of displaying a weapon in a threatening manner.” The inmate was examined by a jail psychiatrist and was confined in a regular cell until charges were dropped three days later.

Sheriff’s Capt. Jim Roache, commander of the County Jail downtown, said the jail has not been directly affected by the changes at Hillcrest. But he said that when the jail’s 24-bed psychiatric unit and 40-bed mental “outpatient” cellblock are full, jailers and psychiatrists are forced to sort out and make decisions on the patients.

“We do the same thing CMH does,” Roache said. “Our units don’t have room for 200 people. So we are picking the worst 24 cases, they’re being admitted to that unit, and we’re carrying 30 to 45 outpatients, and then there are other prisoners receiving some form of treatment through our medical section. And some are being released from custody.”

Hillcrest officials said the overall problem of non-admissions has been exaggerated. UCSD, for example, has hospitalized only about 15 patients in the last six months who should have gone to Hillcrest, they say. County officials also said that, overall, care today is better than a year ago.

“We couldn’t continue running Hillcrest the way we had been, with allegations of inappropriate care, with inappropriate discharges, with staffing problems,” Dr. Harold Mavritte, Hillcrest’s chief psychiatrist, said.

“It was bedlam, with too many people concentrated into a too-confined area. Now there is room to breathe, a much more normative atmosphere where we are able to reduce the number of restraints and the patients comport themselves better.”

State health officials last week agreed with the county’s assessment that Hillcrest now meets or exceeds minimum state standards.

Karenlee Robinson, Hillcrest administrator, added: “We will take 60 people now and not more, so that the 60 will get good care. If we piled them in like before, all 92 would be getting substandard care.” Hillcrest has cut in half its monthly admissions and discharges, from about 300 patients a month to 150, and has lengthened the average stay from 10 days to 16 days, she said.

Mavritte said the county now adheres more closely to standards that he believes should have applied long ago. He said that, for too long, Hillcrest accepted too many people who could have been evaluated and treated at private hospitals or at mental health clinics, without clogging Hillcrest.

“Before, it was bring us your tired, your homeless, we are going to care for them,” he said. “Not any more. That is not our mission. We deal with thousands of people and while many may look bad (to the public), many don’t need to be here, and can utilize other resources to get services that they do need.”

Today, Mavritte said, in order to be admitted to Hillcrest, persons must be evaluated as having a mental disorder that either causes them to be a danger to themselves or to others, or to be gravely disabled, in the sense that their mental disorder makes them unable to perform basic functions such as caring for their dress and nutrition.

But many patients can have their immediate crisis stabilized with drugs and counseling without being admitted to the hospital, Mavritte said. Hillcrest now has set up a treatment program in the emergency room to avoid unnecessary hospitalizations, he said. Mavritte and Robinson also have placed psychiatrists and social workers in county health clinics to evaluate and screen potential Hillcrest clients under “crisis intervention” procedures during daytime hours.

Mavritte conceded that the lack of facilities at Hillcrest can cause problems in the community and that additional funds are needed both for more beds at Hillcrest and for more alternative treatments.

“I don’t think we have any more of a crisis in terms of mental health needs now than we did a year ago, or two years ago, or three years ago,” Mavritte said, “but now it has become more visible because these people are showing up” in hospital emergency rooms in the community.

Mavritte said: “We will take in everyone we can to the limit of our resources, we will keep all 60 beds filled, will evaluate everyone we can, and the only persons we are not going to evaluate in a timely fashion are those that we just can’t accommodate.”

Mavritte said that “5150s” taken to the emergency room by the police are evaluated ahead of requested transfers from other hospitals because of legal obligations. Hillcrest emergency room doctors tell other hospitals requesting transfers to hold patients until they can arrange evaluation.

“Sometimes another emergency room will have to keep someone for three or four hours,” Robinson said. “That’s true. But that’s safer than putting them back out on the street.”

Mavritte said: “And if the police bring someone in who has committed a criminal act, even though that person might be mentally disordered, we might evaluate and say, ‘Yeah, we don’t have a bed now,’ and the safest thing to do is to charge them and put them in jail where they won’t be on the street, where they won’t be a danger to themselves and others, where there is a hospital.”

Mavritte said that Hillcrest must hospitalize patients based on priorities, on the seriousness of the illness, in the same way that police confine felons and release persons charged with lesser crimes when jail space is tight.

“But I do not feel we are putting people out on the street who really need to be hospitalized,” Robinson said. “Our doctors are hired and trained to judge that, unlike people in emergency rooms who may get one or two of these people a month and say, ‘Oh my God, that person is sick!’ even though we evaluate and find they don’t need to be admitted but can get resources” in crisis homes, board-and-care facilities, or outpatient facilities.

However, professional judgments about the threshold for hospitalization differ, Mavritte said, noting the debate with UCSD and Mercy over who needs to be admitted.

UCSD’s Braff defended the evaluations that his own psychiatrists, part of the UCSD School of Medicine, perform in determining that patients need to be referred to Hillcrest and hospitalized. He questioned the consistency of CMH criteria for admissions, adding, for example, that “someone who could become suicidal in a couple of days is not going to be admitted now.

“Some of these patients are well known to us since they have been excluded repeatedly by CMH and keep bouncing back to our emergency room and are finally hospitalized by us at our expense.

“In terms of our standards, it is clear to me that we are doing a thorough, responsible job. And in many ways our normal (mental-health) treatment population . . . is indistinguishable from CMH in terms of seriousness and differs only in that they are not indigent but have Medi-Cal or some other insurance.”

Summarizing the disagreement, Braff added: “We want CMH fundamentally to perform, not just provide 60 beds but perform the function of evaluating and treating patients who are sick and clearly need hospitalization under any reasonable standard.

“And I am angry that the county, by not funding care adequately, is allowing the patients to come last.”