Mental Facility Link Proposed by UCSD : With State Money, University Would Join County in Operation of Hillcrest Hospital

Despite widespread agreement that care for San Diego’s impoverished and violent mentally ill patients would be improved if UC San Diego helped run the county’s Hillcrest mental hospital, political, financial and bureaucratic roadblocks have kept such a change from being seriously considered.

Years of distrust between university and county mental health officials have made both sides wary of making the first move to begin negotiations.

But now, with the county Board of Supervisors about to make a major decision affecting the future of the troubled hospital, and with unrest over a shortage of public mental health beds running high in the psychiatric community, the time may be right for a breakthrough, many mental health experts say.

Dr. Lewis Judd, chairman of the department of psychiatry at UC San Diego Medical School, last week proposed an academic mental health center described as unique in the nation--a UCSD mental health center that not only would solve the crisis in providing indigent care but also would break new ground in psychiatric research and training.

“It’s clearly a logical and rational solution,” Judd said in an interview. “What we want to do is create a showpiece for the country and the world.”

Assemblyman Larry Stirling (R-San Diego), who already has proposed a UCSD solution for the problems at Hillcrest, said he would work in the state Legislature to obtain the funds needed for a first-class operation if university, county and community mental health officials can agree on a concept.

“It’s absolutely doable,” Stirling said. “Once I get political (community) support, it’s a matter of moving it through the legislative process.”

But while county officials agree that a university connection would improve care at Hillcrest, they remain skeptical about whether UCSD, if given full responsibility for the hospital, would spend as much time and energy on patient care as on the research and training that have become the bread and butter of university medical schools.

In addition, one top county official expressed concern over whether UCSD involvement would end up costing the county more money for a service it already is hard-pressed to fund.

“We have always been open to that kind of association, as long as it does not cost us more money,” said David Janssen, the county’s assistant chief administrator. “We are willing to consider all viable options for Hillcrest’s operation, and certainly tying the university into it seems to make a lot of sense philosophically.”

Janssen said an opportunity for the county and the university to sit down together might come as soon as May 6, when the county Board of Supervisors is scheduled to decide whether to move forward with plans to build a new mental hospital near the Sports Arena.

At that point, the supervisors will be asked to mull the future of the county’s acute-care hospital--the only public facility in San Diego for mentally ill patients with no government or private health insurance. Hillcrest also evaluates all emergency patients who appear to have mental problems and then either admits these patients, treats and releases them, sends them to other hospitals that contract with the county or, if they have the means, refers them to private hospitals.

Hillcrest, after months of criticism from state and federal health investigators, has lost its eligibility for Medicare funds because of substandard care. In an effort to improve the care, hospital administrators last summer eliminated one-third of Hillcrest’s 92 beds. The change helped Hillcrest gain state recognition this month for better care, but prompted complaints from private psychiatrists and others that some patients are now being turned out in the street with little or no treatment.

The county concedes that it is at its weakest in recruiting new psychiatrists to work at Hillcrest, where relatively low salaries, difficult patients and a lack of prestige combine to make the jobs rough on even the most eager and public service-minded doctors.

It is that problem that a university affiliation is seen as most likely to solve.

“University medical schools can hire the brightest, highest quality creative individuals who go into medicine,” Judd said. “A quality department can attract quality people, people to make sacrifices to do things they want to do--teach, research and to supervise care--the best young minds interested in academic work in the country.”

Judd emphasized that he is not interested in creating another neuropsychiatric institute like those connected with UC medical schools in Los Angeles and San Francisco. Those institutes, known for their research and training, generally do not treat the kind of poor and violent patients that are found in public hospitals.

Judd said the center as he sees it would be required to deliver effective care for public patients, and that UCSD would be eager to do so. Research and training at the center would be funded separately through the university system with state funds similar to the way that UC now supports the Langley Porter Institute in San Francisco and the Neuropsychiatric Institute in Los Angeles.

Judd emphasized that the state would have to provide new monies to the San Diego campus, since any attempt to reduce funds for San Francisco and Los Angeles in order to support UCSD would be unlikely to succeed politically. Judd estimated that $12 million annually, about the same amount supplied Langley Porter, would be sufficient to set up a large first-class center. The current clinical and research work on mental health at UCSD--with links also to Scripps Research Clinic and the Salk Institute--is highly regarded but on a smaller scale than that at sister UC campuses.

Judd would like his UCSD center to function along the lines of the mental health unit at the Veterans Administration Hospital in La Jolla, which his department runs.

“At the VA, we integrate educational programs, have research fellows, psychiatric residents, and academic and clinical faculty provided for by (funds) from the VA,” Judd said. “We also have full hospital wards and outpatient facilities, and laboratories.”

A new center “would be an inpatient service of effective size to manage the needs of the county . . . sufficient beds to have effective evaluation, an emergency center, to decide which patients need hospitalization, and the opportunity to treat in the most effective, standardized and novel techniques.

“We would have sufficient time to do it effectively, not with pressures of turning patients over prematurely.”

But Judd and others at UCSD made it clear that they would not be interested in providing care for the county’s patients without a dramatic increase in the level of funding now provided by the state.

“The county realizes it would be getting rid of something that has been a headache and an embarrassment,” said Dr. David Braff, chief of inpatient care at the UCSD Medical Center’s mental health unit. “But if all we would get is what they have, then we’d have the headache, not them. That doesn’t make sense.”

Judd’s proposal has already attracted widespread support from the psychiatric community.

“UCSD is a highly respected medical school and the department of psychiatry is highly respected, and they are a little bit slanted toward the biological approach to mental illness, which would make for a much smoother relationship between them and this particular group of patients,” said Dr. Charles Marsh, president of the San Diego Psychiatric Society.

Dr. Rodrigo Munoz, a private psychiatrist who oversees the mental health unit at Harbor View Hospital, said a connection between the county services and UCSD might encourage more private doctors to work part time at the county mental hospital--as clinical professors.

“Both L.A. and San Francisco have large centers for education and training affiliated with the counties--why do we have to have the divisions we have here, why not try to get everyone here to participate together?” Munoz said.

“If we had a large neuropsychiatric unit here affiliated with the university, and private doctors could use it, . . . it would benefit everyone, not just the poor. We have so many new discoveries in psychiatry, and UCSD is producing such excellent research, we should allow the community to benefit from what the university is doing.”

But county mental health officials--long skeptical of the university--aren’t sure how much of their responsibility they want to give away, even though they concede that an affiliation with UCSD would make it easier to recruit top psychiatrists to work with the Hillcrest population.

“I haven’t seen anything (from the university) about UCSD and the county working together, but just the Stirling bill about setting up an NPI and that Hillcrest would become University Mental Health,” said Dr. Harold Mavritte, the county’s chief psychiatrist.

“When I was at UCLA, it was very clear that the school’s mission was not to train clinicians but those who would then teach and help train clinicians, and those who would then do research,” Mavritte said.

“If the university really wants to give service to these people, then an affiliation would be fine,” Mavritte said. “It would enhance UCSD’s training program, it would offer them wider patient selection. And it would enhance our service, enhance our recruitment.”

Mavritte has discussed with Judd, prior to the recent proposals for total university control, about establishing some type of UCSD-county link.

“Initially, that was at a time when Hillcrest was not the best place in the world to work and we were talking about trying to get some of their third-year fellows to work in our screening room,” Mavritte said. But issues of supervision and control of diagnosis proved difficult to overcome in brief discussions, he said.

Mavritte said that until he and Judd sat down last year, there had been general mistrust between the county and UCSD over mental health issues, stemming largely from personality clashes between previous UCSD and county mental health directors. That had manifested itself in county fears that the university was out to take away county jobs by assuming control of mental health in the same way that UCSD established its Hillcrest medical center by taking over the then-County Hospital in the late 1960s.

“Both Dr. Judd and myself agree that we’d like to see something take place but we don’t what form it would take,” Mavritte said. “We have mitigated the general mistrust.”

As a first step, Mavritte suggested, the university might operate an intensive care mental health unit for those patients particularly difficult for the county to manage.

“We have these people with 15 different diagnoses, such as a person we have now with a lobotomy, who appears to be blind, who can’t talk, who suffers from dementia,” Mavritte said. “For me, that is the joy of having the university, to send these sorts of patients to them, to have them do the difficult cases.”

But Mavritte said he’s not convinced that the university needs to run all of the services now provided at Hillcrest. And Dr. David Schein, director of the unit where Hillcrest patients are screened and evaluated, said he doesn’t accept the commonly held belief that a university setting ensures better care than can be had under county supervision.

“It’s almost a theological thing--the UC is the temple,” said Schein, who was a research fellow at UCSD for a year before coming to the county. “I came right out of that temple, and I’m not taken as seriously as if I were still there.

“There is a bit of an air about the county, about it being a negative place,” he said. “I don’t think it’s true . . . I think the decisions we make here are clinically sound.”

Schein and others point out that a university connection with the county does not always work.

In Sacramento, for example, the county for several years contracted with UC Davis to run the mental health program, but that agreement was dropped in 1980 because of mounting tensions between the university and the county over costs and control.

“The university provided excellent service, but they had required an increasing budget each year, which was a problem for the county,” said Ronald Usher, director of health for Sacramento County.

Usher said county officials also believed that they had left to the university key policy decisions that should have been made by elected officials.

“Both the county and the university realized that the county ought to be deciding through its mental health advisory board and the county Board of Supervisors what the program was and how the funds should be allocated,” he said.

In San Francisco and Los Angeles, however, the universities contract with the county to operate public mental hospitals. Despite some tensions, the counties and the schools are pleased with the results.

“I think an affiliation helps both places (county and school),” Mavritte, who worked at UCLA and for Los Angeles County, said. “It has to be a mutual thing. Both sides have to want to do it.”

Stirling believes that a UC connection in San Diego merging the best of what has been tried elsewhere could work, calling Judd “an incredibly capable guy with the stature and reputation to pull it off.

“Judd has to go to his chain of command (the statewide UC system) and get an OK to go ahead, the county needs to add its support, as well as the San Diego psychiatric community.

“If the entire San Diego legislative delegation can (take community support) and go to the Assembly speaker and (Senate) president pro tem and say it wants this done, it can be done.

“Twelve million dollars is not that significant. The state has the money.”