Lawbreaking a Must At Hillcrest Hospital : Crisis Piles on Crisis, With No End in Sight for Indigent Mental Patients

When doctors at the County Mental Health Hospital in Hillcrest turned away mentally ill patients one night two weeks ago, they acknowledged that, in doing so, they probably violated the law.

But officials at San Diego County’s largest--and only public--hospital for the severely mentally ill concede that that occurrence was hardly a new phenomenon at the Hillcrest facility, where cramped quarters and chronic overcrowding frequently force administrators, as one put it, to “pick which laws and rules to violate . . . just to keep our heads above water.”

“We’re constantly operating on the edge and very often have to choose the lesser of evils,” explained Karenlee Robinson, the hospital administrator at Hillcrest. “We find ourselves in the quandary of violating the law by delaying (admitting) patients or violating fire regulations, and possibly endangering patients’ safety, by having too many people in the screening area. You violate a law no matter which way you go.”

From one perspective, the recent 14-hour admissions closure at the Hillcrest hospital, also known as CMH, can be viewed as merely the latest chapter in a long-running story spread over several years in which San Diego County’s mental health program has caromed from crisis to crisis--an unpleasant, often publicly embarrassing saga featuring grand jury and district attorney investigations and wholesale changes of administrators and programs.

Hospital administrators and other county officials, though, characterize the incident as the inevitable product of what Dr. Harold Mavritte, the county’s chief psychiatrist, describes as “the clash between laws and medical responsibilities in an overburdened system.”

“There’s nothing complex about the problem--it’s simply that the demand for services far, far exceeds the supply,” said Mavritte, CMH’s clinical director. “We can handle the normal flow, but anything out of the ordinary-- anything --is going to cause problems. Any pressure in one part of the system is going to cause it to bulge out somewhere else.”

Such a “bulge” occurred at the 60-bed facility about 10:30 p.m. March 5, forcing Mavritte to halt admissions until noon the next day. At the time, 16 patients--about twice the normal volume--were being screened by the CMH staff, five others were waiting in the lobby and several police officers were outside in their cars with other would-be patients.

The situation was exacerbated by the fact that five other hospitals that the county contracts with to provide about 25 additional beds for impoverished mental patients also were full. (Only about half of those beds are available for “routine” patients; the others are devoted to patients with legal problems who might otherwise be jailed.)

“The doors weren’t shut and we never stopped providing care to the people inside, but there was no more room at the inn, so to speak,” Robinson said.

Until the Hillcrest hospital reopened its admissions, police officers intending to drop off prospective patients were told to take them to hospital emergency rooms or elsewhere--creating an unwelcome, but not uncommon, burden for some private hospitals that have had to become accustomed to coping with CMH’s overflow.

Indeed, while the March 5 incident marked the first time that Hillcrest had closed its admissions overnight, officials there and at private hospitals agree that instances in which CMH reaches its capacity and, consequently, must temporarily turn away new patients, are practically a daily fact of life.

“They may not call it closing down, but that’s basically what they do all the time,” said Dr. Lawrence Thum, director of mental health at Mercy Hospital. “Lots of times when we have a patient to be transferred there, they’ll say, ‘Call us tomorrow, we’ll put you on the waiting list.”’

Under agreements with medical and safety officials countywide, Hillcrest accepts mental patients who do not qualify for government or private insurance, as well as evaluating patients from private hospitals who appear to have mental problems. After they have been evaluated, those patients are either admitted to Hillcrest, treated and released, sent to other “contract” hospitals or, if they have the means, referred to a private hospital.

Until mid-1985, Hillcrest automatically accepted all indigent patients on referral from hospital emergency rooms if the individuals appeared to have mental problems. To make room for particularly serious patients at times when CMH was full, less seriously ill patients were discharged.

However, in August, 1985, the Hillcrest hospital reduced the number of its beds by more than one-third and began treating patients longer in an effort to improve the quality of patient care. CMH officials then began telling private hospitals to hold potential mental patients in their own emergency rooms until Hillcrest staffers had the time and space to see them.

Private hospital administrators lament that they now often are forced to keep indigent, seriously mentally ill patients for as long as several days, waiting for admissions vacancies at CMH. Dr. Joel Dimsdale, a top psychiatric administrator at UC San Diego Medical Center, said his hospital kept one such patient for 55 hours last week.

“Getting a patient into CMH is like trying to land at O’Hare Airport in a snowstorm,” Dimsdale said. “Patients are kept in orbit for hours and sometimes days until CMH has an opportunity to even screen them.”

The overcrowded conditions at Hillcrest are attributable to several major causes, starting with what county officials regard as the state’s miserly allocation of beds in state mental institutions that are available to San Diego patients.

San Diego County’s allocation in the state institutions is only 42 beds, which CMH administrator Robinson decries as a “ridiculously low” number for a county with 2.2 million residents. By contrast, Los Angeles and other large urban counties have been allocated hundreds of beds--a factor that figures prominently in a lawsuit that San Diego County has filed against the state, charging that it is being shortchanged in that and other areas.

The scarcity of available state hospital slots “clogs up the whole system,” resulting in many of CMH’s beds being occupied by patients who otherwise would be housed in state facilities, Robinson explained. That, in turn, leaves fewer Hillcrest beds available for new patients who need what doctors describe as “acute emergency” mental health treatment.

Another contributing factor to the patient crunch can be found in the 1985 decision that eliminated more than one-third of CMH’s 92 beds and resulted in longer patient stays.

The reduction to 60 beds, made after several psychiatrists quit and Hillcrest officials were unable to recruit enough replacements, came at a time when the county was under intense criticism from state and federal officials for substandard mental health care. In early 1986, the federal government revoked the hospital’s eligibility for Medicare funds because of those problems. An administrative hearing on that decision, which could result in the county’s eligibility being reinstated before the three-year penalty expires, is scheduled for May.

Officials inside and outside county government agree that the bed-cut solution, combined with a subsequent increase in CMH’s staff, has improved the level of treatment at Hillcrest. Previously, “some corners had to be cut,” Mavritte admitted, in an effort to expedite patient turnover and free needed beds, resulting in many patients being released within a few days. Now, the average patient stay is 14 days, the CMH official added.

However, the answer to one dilemma simply worsened another problem by eliminating 32 beds from an already overextended system.

“Even at 92 beds, CMH wasn’t big enough, so with 60, things have just become that much worse,” Mercy administrator Thum said. “The question is, where are those other 32 people going now?”

Mavritte has a ready response--if not a definitive answer--to that question.

“The answer is the same as where the 93rd and 94th people used to go,” Mavritte said. “I didn’t know where they were going before and I don’t know where they’re going now.” Others, meanwhile, argue that more indigent mentally ill patients now remain on the streets or are shuffled among private facilities that do not want them and whose primary interest is not their treatment but simply turning them over to the county as quickly as possible.

What remains, then, is an overcrowded public mental health system that satisfies virtually no one and generates widespread finger-pointing over who’s to blame.

Disgruntled private hospital administrators complain that the CMH cutback means that they now must devote scarce emergency room space to housing patients who are often loud, aggressive and difficult to handle.

“CMH normally gets the real down and out, worst, worst, worst people who are most ill and most in need of care,” noted Betty Snyder, executive director of the San Diego Mental Health Assn. “You can understand how having to keep them for hours or overnight next to paying patients in private hospitals could cause problems.”

“A crowded emergency room really isn’t the best place for acute psychiatric care,” added UCSD Medical Center psychiatrist Dimsdale. “Wouldn’t it be better to treat these people at CMH so that that (emergency room) space is available to other patients in trauma?”

Police officers also are displeased over having to wait for hours outside CMH before they are able to drop off patients for evaluation. When the Hillcrest facility has reached its capacity, officers often have to “act as a shuttle service” between other hospitals, according to San Diego Police Capt. Bob Slaughter.

“We realize that CMH has a legitimate problem, but they can’t shut down on us and say, ‘Cops, go away,’ ” said Slaughter, head of field operations.

“We can’t have our officers sitting in the car for four hours waiting to drop off someone. It’s a waste of their time and if the person is violent, he could hurt himself. We appreciate their problem, but they can’t inflict it on us.”

State law provides that public mental-health care facilities cannot delay or divert police officers attempting to drop off would-be patients for psychiatric evaluation. Although the temporary admissions closure at CMH earlier this month apparently constituted a violation of that law, “no one has really pressed the point,” Slaughter said.

An oft-heard argument is that the overcrowded conditions at CMH probably result in police officers taking fewer persons 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. Aware that such arrests may result, at best, in an hours-long hassle, police may simply turn their heads the other way on occasion, leaving mentally ill people on the streets.

“I’m sure that’s crossed the mind of at least some officers,” Slaughter said. “But how often is anyone’s guess. It’s like trying to measure a non-event.”

Saying that they are doing as much as their limited space and economic resources permit, county health officials feel that they are caught in the cross-fire stemming from the often competing interests of mental health activists, law enforcement officials and private hospital doctors.

The Hillcrest hospital, which has an $11-million annual budget and a staff, including part-time workers, of more than 270, normally operates at over 95% of its capacity, Robinson said, leaving “only a couple of beds to juggle . . . at any given hour.”

“When the beds are full, what more can we do?” Mavritte asked. “It’s just like an elevator. If the capacity is 19 people, when there are 19 passengers no one else can get in until someone leaves.”

The bed shortage is unlikely to be significantly alleviated, county and other hospital officials say, until the summer of 1988, when a new 111-bed facility in Loma Portal is scheduled to open.

Ground was broken on the project a month ago, but construction work was halted almost immediately by the discovery of old kilns and bricks on the site. Half-jokingly, David Janssen, the county’s assistant chief administrative officer, said that that development, occurring in the wake of so many other woes, has some county officials wondering whether the entire mental health care program is “snake-bitten.”

Archeologists have been swarming over the property for weeks but, assuming that no additional finds occur, they are expected to complete their work within a month, allowing construction to resume.

Even if the new hospital, which will replace Hillcrest, manages to overcome the unanticipated delay and opens on time next year, it will fall short of meeting the area’s public mental health care needs, local officials emphasize.

One statewide study projected that 15 public beds per every 100,000 in population is necessary to adequately provide acute care for adult mental patients--a formula that translates to more than 300 beds in San Diego County, Mavritte said.

“This is a problem that is beyond the capability of San Diego County, both the public and private sectors, to resolve,” Mavritte said. “There probably will never be enough funds to do everything that needs to be done.”

Nevertheless, county officials take heart from their abiding belief that while problems persist at Hillcrest and likely will continue after the new hospital opens, they have made significant strides forward in the past several years.

“Hillcrest is not the same facility it was in 1985,” Janssen added. “Yes, there still are problems. But we’re moving in the right direction. As far as the overcrowding, that’s something that may always be with us.”

Inevitably, any dialogue over the mental health issue focuses on a basic philosophical question: Whose responsibility is it to provide--and, just as importantly, pay for--the care for those unable to pay for themselves?

While that task traditionally has been viewed as primarily a public responsibility, many argue that private hospitals have been unwilling to accept their fair share of the burden--a contention that private officials vigorously dispute.

“Whenever I hear that argument, I have to wonder what our fair share is,” Mercy administrator Thum said. “We do handle as many (indigent) patients as we can. But no private hospital is ever in the position of being able to provide unlimited free care without going bankrupt.”

Even Mavritte sides with the private hospitals in that debate.

“I don’t subscribe to this idea that by not accepting more free mental patients, private hospitals are doing some dastardly deed,” Mavritte said. “I bet there isn’t a single hospital with psychiatric facilities in this county that isn’t eating the cost of treating the poor right now. To expect them to do more is unrealistic and maybe a little unfair.”

Perhaps the most succinct and accurate summary of the issue, however, comes from Hillcrest administrator Robinson.

“When you ask who’s going to pay for acutely ill patients with severe mental problems but no money, you’re raising one of the most basic societal issues that exist,” Robinson said. “And frankly, I don’t know the answer to that question. I’m just stuck in the middle of it.”