Public-private partnerships bring mental health crisis care to uninsured

As the demand for mental health care in California continues to grow, several partnerships are forming to address one of the most pressing needs — mental health crisis care for the uninsured. 

Traditionally, uninsured Californians have had few options for mental health emergencies other than to show up in the emergency room, where they have limited or no access to specialized care. But that is beginning to change.

In August, work began on the Be Well OC Regional Mental Health and Wellness Hub in Orange. The $40 million facility is expected to open next year and house a variety of services such as short- and long-term mental health treatment, crisis-stabilization units and substance-abuse treatment programs.

Riverside County, meanwhile, is set to open a 100-bed behavioral health facility at the end of 2020 in Palm Springs that would serve uninsured and underinsured patients.

And in Sacramento County, Dignity Health has partnered with the county to open a $1.8 million crisis-stabilization unit located next to the emergency department at Dignity Health's Mercy San Juan Medical Center in Carmichael. This unit is essentially a 3,400-square-foot common room where patients can relax in recliners, avail themselves of psychiatric services, and leave with resources for follow-up, regardless of insurance or immigration status. 

Dr. Richard Afable knows the challenges uninsured Californians face in navigating an environment that is missing a coherent, continuous system of care for those battling mental illnesses.

Afable is president of Mind OC/Be Well OC, a nonprofit that aims to stitch together a comprehensive system for mental health that will help individuals access treatment regardless of whether they are insured, by partnering with local government, faith leaders, hospitals, insurance companies, mental health advocates and law enforcement agencies.

Partnerships and creative solutions

Mental health services have become so challenging to access that strategic partnerships and creative solutions have become imperative, Afable said.

"Innovation is an important part of where mental health services are going," he said. "Approaches such as group therapy, telehealth and telemedicine, prevention education -- all have a part to play. Going to emergency rooms is the only choice for many uninsured people right now. But they don't get specialized care there."

The other option for the uninsured is to go to federally qualified health centers, which are federally funded clinics that offer a range of services to underserved communities. People without insurance can pay on a sliding scale depending on their income level. However, while such clinics are equipped to treat ongoing conditions such as depression or anxiety, they are not equipped to handle crisis situations, Afable said.

Orange County spent $7.5 million last year to purchase the 2-acre site. The Board of Supervisors committed another $16.6 million in January to the Be Well partnership, which includes the county’s Health Care Agency; CalOptima, the county’s health insurance provider for the indigent; and hospital systems Kaiser Permanente and St. Joseph Hoag Health.

The 60,000-square-foot facility won't turn away anyone who is seeking help -- whether they’re insured or uninsured.

A formidable challenge for the uninsured

These types of facilities are necessary to bridge the gaps in the mental health system that prevent the uninsured from accessing the care they need, said Jan Emerson-Shea, spokeswoman for the California Hospital Association.

"Being uninsured is really a deterrent when it comes to getting care," she said. "If you have a mental health crisis, you will get basic treatment. But the challenge with emergency rooms is that most hospitals are not set up to deal with crisis situations unless they have an inpatient psychiatric clinic, which is rare."

Hospitals are "providers of last resort" in mental health crisis situations, Emerson-Shea said.

"But if someone comes in with a mental health crisis, we will do what we can to save a life and help them get services," she said. "But often we deal with physical health and not mental health. Patients might have to wait several days to see someone who has the expertise to give them the care they need."

According to the California Health Interview Survey, more than one in five adults in the state reported needing help for emotional or mental challenges or alcohol or drug use in 2018. The number of inpatient hospital psychiatric beds fell nearly 30% from 1995 to 2016, according to the California Hospital Foundation, a decline of more than 2,650 beds. Over the same period, the state’s population grew by more than 7.5 million people. 

Another study published in JAMA Network Open in October 2018 linked a mental health diagnosis with an increased use of emergency department visits. Researchers also found that Medicaid coverage and lack of insurance were associated with greater emergency department use than those with private insurance.

Taking care to the streets

These trends coincide with a spike in homelessness in the state that has reached crisis levels and where mental illness can often be a factor. Brett Feldman, the USC Keck School of Medicine street medicine director, is working in Los Angeles to address that part of the problem.

While there are many providers that serve homeless people at clinics and some mobile services, he aims to provide mental health care in ways that are even more accessible, regardless of insurance status. 

He said it’s important that health care professionals “stretch their scope of practice and become comfortable with providing a certain level of psychiatric medicine on the streets,” given that those who are homeless or uninsured are unlikely to have the funds or transportation needed to make it to a mental health facility.

Feldman provides antipsychotic medications on the streets to treat conditions such as bipolar disorder and schizophrenia, and Suboxone for medication-assisted treatment. He does this by providing a monthly injectable medication, eliminating the possibility that someone might lose the medication, have it stolen or forget to take it.

“It’s actually pretty easy to track people down once a month and maintain their care management,” he said. “Most people have pretty predictable lives -- we all usually do the same things and follow the same schedules, even individuals who are living on the streets.”

Innovative models of care

Meanwhile, counties around California are trying to come up with their own solutions, including Riverside County’s planned facility in Palm Springs.

It’s otherwise nearly impossible for those without private insurance to access mental health care, said Greg Rodriguez, the Riverside County Board of Supervisors' public policy adviser.

If patients are uninsured but qualify for Medi-Cal, they will be signed up by staff at the facility. If patients don’t qualify or are underinsured, they would still receive a range of services at the planned facility — from stabilization after a crisis to getting connected to a counselor, therapist or case worker, he said. 

“It will serve anyone regardless of insurance because we think those people are the most vulnerable populations, and we know treating mental health and behavioral health is a key issue to overcoming related issues like homelessness,” Rodriguez said.

The facility will offer overnight care and outpatient services. It will be funded through Riverside County’s behavioral health department.

“We are really trying to create an innovative model that can fill in the gaps not addressed by expensive facilities,” he said.

Moving forward, Rodriguez said the goal is to expand the number of mental health beds throughout the county for everyone, regardless of their insurance status. But for now, he said, the priority is serving those who are uninsured and underinsured.

Continuum of care

The Sacramento County area served by Dignity Health’s crisis-stabilization unit has many patients who seek mental health services but whose needs often go unmet, said Rosemary Younts, senior director of behavioral health services at Dignity Health's Sacramento Division.

Dignity Health invested in the common-room facility, and the county provides ongoing funding, she said. The unit can accommodate 12 people and is always open.

"We went with a common room rather than separate bedrooms because it feels less like a hospital and provides a more calming environment for recovery," she said.

The unit also has a robust research center staffed by peer and family navigators. When individuals are ready to be discharged, they can go to the research center to get linked to outpatient services, social support or primary care services.

"It's about providing that continuum of care, which is currently missing from our mental health system," Younts said.

For the coming year, Sacramento County has proposed using about $19.3 million from its Mental Health Services Act funding for a number of innovative projects, including crisis care clinics, behavioral health services, residential services and suicide-prevention measures, said Ryan Quist, the county's director of behavioral health. 

This funding was made possible by the passage of Proposition 63 in November 2004, which allocated more resources to support county mental health programs serving those with and without insurance, and regardless of immigration status.

Quist said the county has a range of services, including 10 mental health respite centers where individuals experiencing a mental health crisis can turn. These individuals would typically be referred to these centers by area emergency departments. A number of homeless people have made use of these centers as well, he said.

The county also has a mobile crisis-support team through which mental health professionals ride along with police and offer help in scenarios where mental health may be a factor.

In addition, prevention services are offered to diverse residents in the region, including Latino, Asian, Native American and Russian-focused efforts, Quist said.

The county's partnership with Dignity Health is yet another way to fill the gaps and provide that continuum of care for mental health services, he said.

Follow the USC Center for Health Journalism Collaborative series "Uncovered California" here.