County to Cut Many Services for Mentally Ill

Financially ailing Los Angeles County has quietly begun dismantling its system of treating the mentally ill, and plans to eliminate its huge outpatient psychiatric headquarters at County-USC Medical Center as well as inpatient and outpatient psychiatric services at its other hospitals, according to documents and interviews.

The county’s network of mental health clinics and even some private hospitals will be expected to take over that psychiatric work, but mental health officials said Thursday that the overflow will be overwhelming.

As a result, officials said that thousands of the county’s most seriously mentally ill will be cast adrift, with little direction and far fewer established places to go for counseling, medication and medical care--including psychiatric hospitalization and long-term care.

County officials cite continuing budget problems in the beleaguered Department of Health Services as the primary reason it will cease its decades-long practice of providing services for the mentally ill. The only vestige will be some crisis care at a downsized psychiatric emergency room at County-USC.

The Board of Supervisors has approved transferring responsibility for all mental health services to the county Department of Mental Health, which has provided mostly outpatient and residential care since 1978.

Mental health officials concede that they have yet to come up with a contingency plan for handling the patient load. Mental Health Director Areta Crowell said that only 40% of the estimated 5,000 patients who receive acute inpatient care each year will continue to receive treatment.

“With the DHS meltdown, we have to develop an alternative system to what they had provided,” Crowell said. “A lot of people won’t get served. They will fall through the cracks. I can’t describe it any other way.”

Besides having severe financial problems of its own, Crowell said, her department was given just a few months to undertake such an enormously complex and expensive task with practically no extra money in its $350-million budget.

“If you said to anyone we’re going to close four psychiatric hospitals in a year, that would be a challenge,” she said. “To have to do it like this is unthinkable.”

Crowell said she hopes that a minimal safety net will be in place once contingency plans are finalized in the coming weeks.

But Raul Caro, County-USC’s administrator for psychiatric services, offered a grim assessment of the downsizing.

“The mental health system is going down the tubes,” he said. “We are ratcheting down, to possibly providing some form of emergency triage psychiatric services in an emergencyroom setting. But that is it.”

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Dr. Marc Graff, president-elect of the Southern California Psychiatric Society, said his members are so concerned that they are preparing a letter asking the county to reconsider. “A system that has been built up for decades, with research, education and patient care, is being absolutely dismantled right in front of our eyes,” he said, “with little thought about the consequences of anyone involved.”

“It is a sacrifice to moola, to money. And these are the least able patients to take care of themselves,” Graff said. “They will not be protesting in the streets. They will be sitting in front of their own doorways in despair.”

All of the closures are slated to be completed by Oct. 1. And with no alternative system in place, county doctors are growing anxious. They say they do not know what to tell patients who are beginning to ask questions about whether they will continue to receive care, and, if so, where.

At Dr. Nolan Thompson’s group therapy session Thursday for the seriously and chronically mentally ill at County-USC, nearly all of his nine patients asked him what will happen next. “They were all asking, ‘Where are we going to go? What are we going to do?’ ” Thompson said. “And I could not tell them. We have been given no direction on that.”

With so much silence regarding what will be left of their safety net, patients are panicky. Many fear that even temporary lapses in their medication and treatment will break a precarious cycle of stability that could send them back to the streets.

“If they close [the center], I don’t know where to go. I don’t know where to get my medicine. I am going to have a lot problems,” said a 21-year-old schizophrenic who said his mood disorders often make him violent. Added his doctor, John M. Murphy: “They don’t have a clue where patients like him would go. They have just completely dropped the ball on this.”

The downsizing of the entire mental health system, county officials say, is the result of an unfortunate confluence of many factors, most significant a budget deficit in the Health Services Department that is far worse than the $655-million estimate.

The health department had run much of the county’s mental health system because many of the mentally ill need hospital care, medical treatment or prescription drugs that hospitals and clinics can provide. But all that changed when the supervisors this month adopted a report by the Health Crisis Task Force, which recommended that all mental health services be transferred to the Department of Mental Health.

On Wednesday, mental health Director Crowell officially notified her management staff that they would now have to take over inpatient and outpatient services once provided by the health department with all of its hospitals, comprehensive health centers and clinics, most of which also are closing.

“Please be aware that the transfer of these services to DMH was not our recommendation or our preference,” Crowell said in a management memo obtained by The Times. “Since we have been given the task, we must now proceed to do the best we can.”

Now Crowell must come up with a contingency plan for where to send the mentally ill for outpatient treatment and continuing care. She also must determine where to house all of the hundreds of inpatients, many of them violent or so mentally ill that they need hospitalization, medical care and constant attention.

Because there are so many functions that the mental health department cannot provide, such as the inpatient services at County-USC, Crowell said she is trying to negotiate contracts with other hospitals and mental health clinics. She hopes that they will accept the inpatients, as well as the constant stream of violent and seriously mentally ill people who pour into county hospitals and require immediate treatment because no other hospital wants them. Most of those mentally ill treated by the county are indigent and do not have Medi-Cal.

“We had a reasonably well-functioning system of care for those seriously mentally ill in the county,” Crowell said. “But this is a massive disruption. Even if we can purchase services and make some alternate arrangement, it will be a long time before it will function as efficiently and effectively as what we have had. We are just trying to get this network set up.”

Doctors at County-USC praised Crowell for trying so hard to replace the system that they say is being dismantled. But they said Thursday that that is impossible, that many private health care providers will only take those well-mannered patients who are insured by Medi-Cal or some other carrier. They also said many of their patients have such specialized requirements, including the need for a combination of psychiatric and hospital care, that they will be in danger if they are sent anywhere else.

“This is a nightmare; these people are going to end up in jail, or under freeway overpasses,” said Dr. Calvin Flowers, chief resident in County-USC’s psychiatry department. “What concerns me is that [Crowell] admits she cannot provide these services. But she doesn’t say what she is going to do.”

Some Department of Health Services administrators, although they continue to have problems of their own, said they are watching the downsizing of the mental health system with disgust.

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“The whole thing is such a disaster I don’t even want to talk about it,” said one top administrator in the Department of Health Services, Dr. Jonathan Weisbuch. “There are 200,000 people in this county with serious mental illnesses. To try to close down the mental health resources in our six hospitals to save a few pennies in the broad scheme of things is unconscionable.”

In other developments Thursday:

* A week after dodging a more severe financial threat, the Metropolitan Transportation Authority agreed to sit down with county officials to negotiate a one-time transfer of $50 million to the county’s depleted coffers. The move grew out of a proposal by Gov. Pete Wilson, who last week vetoed a broader measure that would have allowed the county to raid the MTA budget for $75 million a year for five years.

“It’s a compromise that says [to state lawmakers]: ‘Don’t bring back any more legislation to take money from us,’ ” MTA board Chairman Larry Zarian said in an interview.

* The supervisors began the process of trying to raise as much as $22 million through increased taxes in the county’s unincorporated areas. At a hearing on the issue, Jack Kyser, chief economist at the nonprofit Economic Development Corp., said a proposed 2% tax on ticket sales at Universal Studios and Six Flags Magic Mountain would scare away tourists and provide little additional revenue.

In all, the board is considering raising taxes on cable TV companies, water users, sewer users, business owners, hotel and motel operators, trash collectors, landfill operators and amusement parks. The board is scheduled to vote on the tax increases after a second public hearing Aug. 24.

Times staff writers Eric Lichtblau and Timothy Williams contributed to this report.