County Supervisors To Vote To Close Gaps In Programs For Severely Mentally Ill

There may be as many as 10,000 people living in San Diego County with severe mental illness who don’t know they are sick.

In the worst cases they are a danger to themselves and others. They wind up cycling in and out of jails and prison, in and out of emergency rooms, on drugs and living on the streets of San Diego County.

In March, the Board of Supervisors tasked County health administrators with reviewing the system of care for the seriously mentally ill. Health administrators had 90 days to compare the County's current voluntary services to Laura's Law, a mandatory, court-ordered treatment program.

County health administrators released a report earlier this month. They recommended the Board of Supervisors expand the county's voluntary In-Home Outreach Team, or IHOT, program, and consider a path for adopting Laura's Law.

County Mental Health Director, Alfredo Aguirre believes it's the County's responsibility to provide a "safety net" service system for people with serious and persistent mental illness.

But he says there are barriers to adopting Laura's Law here. The county doesn't have the money to pay for the program, and funds from a state mental health law cannot be used for it. There is a bill making its way through the state legislature that would clarify funding restrictions, but it won't be voted on until September.

Voluntary Versus Mandatory Treatment

Some mental health advocates are critical of the County because they say people who need mental health services but refuse treatment are falling through holes in the public "safety net" that's intended to help them because the County does not have a court-ordered treatment program like Laura's Law.

Aguirre said more than 41,000 adults get mental health services from the county. Of those, he said 1,100 of the highest risk people participate in the County's "assertive community treatment" programs called full service partnerships.

James "Diego" Rogers runs one of these programs for the Community Research Foundation. He said they've been successful in getting people who are resistant to treatment into the program.

"We’ve been able to see results where through the aggressive outreach, see individuals go from being homeless one day to have an apartment or housing the following day," he said. "The mental health services are delivered in the community where the client is residing or even out on the streets – bringing the psychiatrist to them, bringing the clinicians to them."

But gaps in services have contributed to repeat hospitalizations and a failure in outpatient treatment, said Dr. Michael Plopper, chief medical officer for Sharp Hospital's Behavioral Health Services.

He said about 4,000 people are admitted involuntarily to Sharp hospitals in San Diego County each year for 72-hour psychiatric holds.

"Our charge is to connect them with continuing care after discharge and we have some significant roadblocks to that," he said.

One option is to admit people to an Institution for Mental Disease. These are locked facilities that provide long-term psychiatric care. Patients stay in IMDs for about six months and progressively become more independent as they integrate back into the community.

But there is only one in San Diego County -- the Alpine Special Treatment Center.

Brian Miller is the center's chief psychiatrist, and he said when he began practicing psychiatry here in 1997, San Diego had three such centers.

"There’s been a very deliberate effort to reduce those beds," Miller said. "My understanding is that primarily has to do with cost and so we have about 150 less long term care beds in San Diego than we did.”

Aguirre said the County focused its efforts away from using long-term care facilities and into lower levels of care like the full service partnerships for several reasons. For one, the county could not use state funding for the longer-term care, and medication improvements have made that kind of care less necessary.

But Plopper said the need for long-term care persists. People often spend several months in Sharp's psychiatric hospitals waiting to be transferred into a long-term care facility.

And because San Diego has only one facility, patients are sometimes sent outside the county, which creates its own set of complications.

"I believe it’s not consistent with the recovery model to send a 28-year-old schizophrenic young woman to a locked skilled-nursing facility out of her county, away from her family and residing with older people with dementia," he said. "I just don’t think that’s a solution, that’s what we’re living with today."

Conservatorship

One option for getting a severely mentally ill person into a stable living situation is appoint a conservator -- someone who is allowed to make decisions on their behalf. Even that can be tricky, though.

Shelly Kwik, said her son Evan had a dual diagnosis — mental illness and addictive disorder — and because of that it was too hard to get a conservatorship because doctors could not necessarily diagnose the whether drugs or mental illness were the root of his problems.

“I called legal aid and asked them if they could help me get him under a conservatorship and they said 'no' because he was doing drugs and they said it’s much more difficult if someone is doing drugs,” she said.

James Rogers, who runs the full service partnership, said mental health and substance abuse disorders used to be treated separately but that is changing as clinics try to adopt comprehensive approaches to treating people with mental illness and addictive disorders.

The Revolving Door To Prison

Another problem that families of the severely mentally ill face is the cycle of incarceration.

Anita Fisher said her son Pharoh Degree, who is diagnosed schizophrenic, has been missing since he was released from Donovan State Prison just a few weeks ago.

She said her son was held in the psychiatric area of the prison but when he was released, there were no resources for him.

"There is no connection to services, there is no connection that this person needs. I refer to it as a warm hand off, where someone does pick him up and does take him and connect him to the services that he might need," Fisher said. "'Because my son has a choice in if he wants us to pick him up. We were ready and available to do that. But if he doesn’t let us know exactly what time he’s leaving, we don’t know. We can’t so we’re just here now with a missing person."

Alfredo Aguirre, the county's mental health director, said funding cuts related to prison realignment have resulted in reductions in services at state parole outpatient clinics.

"The resources available for these kinds of people who need this kind of outpatient care, not just the basic medications but also case management has been reduced," he said.

He said the County has tried to bridge the gap left by cuts to state parole programs.

"They often call us and we try to do our best to complement what they can’t provide," Aguirre said.

He said under realignment, the state's program to transfer supervision of people convicted of non-violent crimes to the counties, more people are falling under local jurisdiction of the County's Probation Department.

"The good thing there is a lot more services are offered to those individuals. We offer all our levels of care, both substance abuse services as well as mental health services depending on the need," he said.

He said people released from County jails can be court-ordered into treatment.

Next week Aguirre will make recommendations to County Supervisors on how best to improve the "safety net" for the severely mentally ill.

He'll recommend the county expand its In-Home Outreach Team, the County's voluntary treatment alternative to Laura's Law, the mandatory program. He'll also recommend a path to possible adoption of Laura's Law.

Plopper said he thinks the in-home program is great but isn't enough to reach mentally ill people who resist treatment.

"There are a set of people in this community, probably about 1,000 who have serious mental illnesses, and aren't aware they have those illnesses, or unwilling to accept those illnesses, and can be a danger to themselves or others," he said. "Assisted outpatient treatment through Laura's Law allows a remedy, and allows us to monitor and treat those individuals."

On July 30, San Diego County's Board of Supervisors will vote to accept the agency recommendations, or not.

This story originally ran on KPBS.org on July 24, 2013.