Hospitals’ challenge: where to send homeless mentally ill

More than three years into L.A.’s crackdown on patient dumping downtown, officials have reached settlements with four hospitals and collected millions in payments.

But although enforcement has been aggressive, much less has been done to address the problem at the heart of the issue: If patients can’t be left on skid row, where should they go?

Skid row has the region’s largest concentration of social services for the homeless, and hospitals have long said patients without families have few other options.

After The Times first reported the homeless dumping problem in 2005, county officials proposed creating five regional homeless centers designed to spread out services and take pressure off skid row. But that plan fizzled -- and downtown remains the prime location of service providers for the homeless.

While activists decry the practice of hospitals simply dumping patients on skid row without planning where they will go, they acknowledge that finding care for such patients is difficult. The situation, they said, reveals a major weakness in the region’s safety net for the homeless and mentally ill. There are fewer than 100 shelter beds in Los Angeles County reserved for homeless people with chronic psychiatric issues.

“On any human level,” said UCLA law professor Gary Blasi, dumping a mentally ill homeless patient anywhere is “really outrageous. On the other hand, I have some sympathy, if not some understanding, of the plight of a discharge planner in a hospital looking for a suitable place to which to discharge a homeless person with severe and chronic mental illness. The numbers of facilities that are actually set up to receive people in that category are extremely low.”

Indeed, some hospitals have said they are caught in a Catch-22 situation. State law obligates them to provide appropriate discharge planning, but there are not always adequate services available for homeless patients -- especially those with mental conditions.

The L.A. city attorney’s office announced a settlement Wednesday with College Hospital, which has facilities in Cerritos and Costa Mesa and allegedly dumped more than 150 mental patients in the downtown area in 2007 and 2008.

As part of the settlement, the hospital agreed not to send homeless patients to the streets or shelters in a “patient safety zone” -- downtown and much of South-Central Los Angeles. If that condition is violated, hospital officials could face a stiff fine and possible jail time. The hospital also agreed to develop specific discharge protocols.

“We didn’t want any kind of debate or loophole over whether the patient consented,” said Jeffrey B. Isaacs, chief assistant Los Angeles city attorney. “We wanted it to be as clear and as mean as possible. There is no good reason to bring someone from Cerritos or Costa Mesa to skid row.”

The discharge rules for College Hospital are still being worked out, and experts said the devil is in the details.

Ellen Satkin, program director of the Patients’ Rights Office at the Los Angeles County Department of Mental Health, said discharge planning for psychiatric patients, particularly if they are homeless, must start the minute they are admitted to a hospital.

“You have to work with the patient and find out what their wants and desires are, where they came from and what their resources are,” Satkin said. But, she added, “if the person is indigent, it’s a little more challenging. There isn’t much out there.”

Board and care facilities, one of the major discharge destinations for homeless psychiatric patients, are primarily businesses -- and not all patients have filled out the requisite paperwork to qualify for state and federal assistance.

Fran Hutchins, a policy and planning analyst at the Los Angeles Homeless Services Authority, said the issue is not whether there are enough shelter beds, or whether board and care facilities can handle the load of indigent patients, but whether the region has enough permanent supportive housing to care for them.

Under that model, people live in a building with on-site medical clinics, mental health care and alcohol and drug treatment, funded with both public and private dollars. In most cases, the residents are given the time they need to seek treatment and apply for disability.

“Whenever attention comes to this issue, it gives us an opportunity to think about not just shelters but building the permanent supportive housing to end homelessness for this really vulnerable population,” Hutchins said. “Unless we end homelessness, they are going to keep showing up in hospitals and having problems with discharge planning.”

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cara.dimassa@latimes.com

richard.winton@latimes.com