Patients who would have been admitted to San Diego County's Hillcrest mental hospital a year ago are now being shuffled among other hospitals and mental-health providers less well-equipped to handle such cases.
Some of these patients are being turned out on the street with little or no treatment, some mental health officials say.
The patients, many of them violent and most of them without money or private or government health insurance, are being treated differently as a result of the Hillcrest hospital's decision to eliminate one-third of its 92 beds and treat each patient for longer than before.
Combined, the two policy changes mean that Hillcrest, San Diego's largest (and only public) hospital for the severely mentally ill, is now admitting only about half as many patients as it did a year ago. The director of one hospital emergency room said psychiatrists there sometimes are reluctant to send suicidal or homicidal patients to the county for fear that the patients will be turned away or released without adequate treatment.
But county officials say those patients who get into Hillcrest today receive far better care than when the hospital had more beds. The officials say that the county's sickest people are still granted admission but that many persons who traditionally have come to their doors can and should be treated without admission or referred to other, less restrictive, medical facilities.
County officials argue that the underlying problem is a lack of public funds for the mental health care system, a situation they alone cannot solve.
The reduction in beds--from 92 to 60--was a key move last year in county efforts to improve the level of treatment at the troubled acute-care hospital by decreasing the number of patients seen by psychiatrists and increasing the number of days the patients remain hospitalized. The beds were cut after several hospital psychiatrists quit and Hillcrest officials were unable to recruit enough replacements--leaving the facility with just three full-time doctors.
At the time, the county had been under intense criticism by state and federal health officials for substandard care, and early this year the federal government revoked the hospital's eligibility for Medicare funds because of those problems.
But the bed-cut solution has unleashed strong criticism from other mental health providers in the county.
"It's as if a poor husband and wife with five children, all malnourished, shoot three of the kids to help feed the other two a little better," Dr. David L. Braff, director of inpatient psychiatric services at the UC San Diego Medical Center, which is next to the Hillcrest hospital (also known as CMH).
"Even when CMH had 92 beds, that was probably too low for a county this size," Braff said. "But now what they have done is disperse the problem into the community.
"We have a total mental health disaster because the system is underfunded and inadequate in the number of people to be treated."
Under agreements with safety and medical officials countywide, Hillcrest takes patients with mental health problems who do not qualify for government or private insurance; it also evaluates all emergency patients who appear to have mental problems. Once evaluated in the Hillcrest emergency room, these patients are either admitted, treated and released, sent to other hospitals that contract with the county or, if they have the means, referred to a private hospital.
Until last summer, Hillcrest automatically took all indigent patients on referral who went to UCSD or other hospital emergency rooms and appeared to have mental problems. If CMH were full and received a particularly serious patient, a less seriously ill person was discharged to make room. Now Hillcrest tells private hospitals to hold those patients in their own emergency rooms until CMH has time to see them.
As a result, the patients--often loud, aggressive and difficult to handle--must either be released or kept in emergency rooms for several hours until Hillcrest can accept them for evaluation, though with less assurance than before that they will then be hospitalized.
The emergency rooms at UCSD and Mercy Hospital have borne the brunt of the change, officials say. UCSD, so close to the Hillcrest facility, treats the county's physically ill indigents and serves mentally ill patients who have government insurance such as Medicare and Medi-Cal. Mercy, about half a mile from UCSD, provides a full range of medical services to private and government-subsidized patients.
"The homeless wander down the street and often end up at Mercy," said Dr. Lawrence C. Thum, medical director of Mercy's mental health unit. "Before, we would find it quite easy to get this type of violent patient transferred to CMH, traditionally the single place within the community to take care of such people.
