Children in Crisis Wait for Days in Calif. ERs for Transfer to Mental Health Facilities

Oct. 04--When Jessica's 7-year-old son went into an uncontrolled rage in February, punching his mother and trying to break the windows in their home, he was taken to the emergency department at Modesto's Doctors Medical Center for an evaluation.

Rather than getting prompt treatment for his mood disorder, the boy spent four days in the ER waiting for a bed to open in a psychiatric facility far outside Stanislaus County. Only a curtain separated the boy from eight adults who had been placed on psychiatric holds.

Jessica, who asked that her name be withheld because of a looming custody battle, stayed at her son's side each night until 11 p.m. and cried when she left him overnight.

When a bed finally opened at a pediatric mental facility in Bakersfield, 200 miles away, family were not allowed to accompany the 7-year-old boy on the three-hour ambulance ride.

Jessica, who couldn't leave her job, worried constantly about how her son was faring. She had to jump through hoops to get him on the phone, she said.

"I was scared; they have your baby and you don't know them," the single mother said. "If something bad were to happen, I am three hours away."

She drove to pick him up in Bakersfield upon his release, and two months later his severe disruptive mood disorder erupted again. This time it was 2 1/2 days in the emergency room, another ambulance trip and four days without mom in a Sacramento facility.

Stanislaus County mental health officials say the same thing happens to suicidal adolescents, who are held in local emergency rooms instead of getting prompt intervention. The teens are ultimately sent far outside the county because of the severe shortage of psychiatric units for children in California.

In 2012, The Modesto Bee and the nonprofit Center for Health Reporting reported that emergency rooms had become way stations for psychiatric patients who needed care. People placed on involuntary holds because they are a danger to themselves or others are sent to psychiatric hospitals to be stabilized and are released with referrals to outpatient services.

Emergency rooms are often a first stop for these patients because they require medical screenings and an evaluation of their psychiatric symptoms.

Last year, Stanislaus County opened a 16-bed psychiatric health facility, which added capacity for stabilizing adults. In addition, hospital officials say they have reduced the wait times for adults with psychiatric conditions by streamlining the transfer of patients to Doctors Behavioral Health Center on Claus Road.

But no one has fixed the problem for children.

"We do our best to put them in the quietest place we can find in the emergency department," said Carin Sarkis, spokeswoman for Doctors Medical Center.

The hospital meets their basic care needs, but they are not getting the psychiatric interventions they need, she stressed.

Limited options for children

Madelyn Schlaepfer, director of county mental health, has pointed out the trauma suffered by children and their families of out-of-county hospitalizations and long ambulance trips.

She said most of the children held in ERs are 12 to 17 years old, and they may wait for days for a bed in the Bay Area, Sacramento, Fresno, Bakersfield or even Southern California.

There are even fewer options for younger children such as Jessica's son.

In a recent report to the county Board of Supervisors, Schlaepfer wrote that children in crisis are apt to be placed in emergency departments near adults exhibiting psychotic symptoms. That is not good for the mental condition of the kids, her report said.

"Children and youth become increasingly distressed beyond the state in which they were brought into the emergency department," Schlaepfer wrote. "The increased stress further aggravates an already difficult situation, making recovery less likely to occur quickly."

The county has used crisis intervention to reduce hospitalizations for adults and hopes to do the same for children, Schlaepfer said.

It is now working on a plan to lease space near Doctors Medical Center on Florida Avenue for a crisis intervention unit. Children taken to the unit would be assessed and stabilized with medication and their parents educated on how to keep them out of crisis. County supervisors are expected to consider the proposal later this month and services could begin next year.

Schlaepfer's department also wants to focus more mental health services on those children with the most severe disorders, so they stay out of crisis and do not need hospital care. At any given time, the county is responsible for four to 12 children in psychiatric hospitals elsewhere in the state.

Lucinda Chiszar of Modesto said she takes her 12-year-old son to the ER or calls 911 when he explodes and tries to hurt his parents or himself. The boy struggles with bipolar disorder with psychotic features. Although the right balance of medication allows him to attend school under an individualized education plan, some days are difficult for the family.

"Once he tried to clock me with a chair because I asked him to brush his teeth," Chiszar said.

During an episode in spring 2013, her son was taken to Emanuel Medical Center's emergency room in Turlock. With no space available in the ER, he could not stay in the waiting room and was placed on a gurney in the hall, Chiszar said.

"The ER doctor came and said it could be his medication," Chiszar recalled. "He shrugged his shoulders. He did not know what to do."

Her son's agitation went away in five or six hours and he returned home.

Narrow network, options

Emergency room "boarding" of psychiatric patients is one symptom of what is a national mental health crisis. A 2010 article in the journal Health Affairs said the number of beds in mental hospitals shrank from 400,000 in 1970 to 50,000 in the mid-2000s. California has lost 40 percent of its acute psychiatric beds since 1995 and has a need for 4,000 additional psychiatric beds, according to the California Hospital Association.

Psychiatrists are not available in many medical hospitals, and staff members in emergency departments are often not trained to care for psychiatric patients, the Health Affairs study found.

Officials said the crisis intervention and intensive services for children would benefit the uninsured and families on Medi-Cal because of the county's mandate to serve that population.

But for parents such as Chiszar, who have private insurance, they are forced to seek help for their kids from a narrow network of professionals in the Northern San Joaquin Valley.

The most recent surveys show that the San Joaquin Valley has eight psychiatrists per 100,000 population, lower than any region in California. Meanwhile, its rates of serious mental illness in adults and severe emotional disturbance in children rank among the state's highest, according to the California HealthCare Foundation.

Chiszar, who has a second child with mental health issues, said it can take nine months to get an appointment with a pediatric psychiatrist for an initial diagnosis, which is needed for outpatient treatment and other services. Local therapists tend to come and go, forcing parents to constantly find new providers, she said.

In response to the shortage, the Modesto-based Valley Consortium for Medical Education has proposed establishing a four-year program to train psychiatrists in Stanislaus County.

Doctors Medical Center and Memorial Medical Center, along with the county, are partners in the consortium, and the hospitals see increasing impacts from patients who come in with untreated mental illness, said Dr. Peter Broderick, who leads local physician-training programs.

Broderick said mental health and general health often deteriorate in tandem.

Many of those patients are admitted repeatedly to the hospitals, causing a growing financial strain.

The residency program would bring 12 to 16 residents to town, plus four veteran psychiatrists to teach them, Broderick said. Instead of a medical doctor shrugging his shoulders, patients in the ERs would be seen by psychiatric residents supervised by faculty.

Residents also would rotate to clinics, and about half would likely stay to practice in the community, boosting local access to mental health care, Broderick said. The consortium is working on a needs assessment and cost analysis and may look to add partners to help finance the $2.8 million a year program.

In the past three years, while pressure on medical hospitals from psychiatric patients has not let up, hospital officials say they have managed to reduce emergency room "boarding" of adults.

Dr. Robert Barandica, medical director for the Doctors emergency department, said the hospital has not seen fewer patients with psychotic symptoms since the county opened its Psychiatric Health Facility in 2013. The patients are held for shorter periods, however, thanks to a routine in which ER doctors medically screen patients and then transfer them to the hospital's sister facility, Doctors Behavioral Health Center, which handles the psychiatric evaluations.

Patients do have to wait for transportation, but hours of operation have been expanded. Three years ago, Doctors Behavioral Health Center's intake unit was closed from 10 p.m. to 8 a.m.. Now, it's open around the clock.

Tony Varton, chief executive officer of the center, said about 40 percent of patients assessed in the intake unit do not meet the facility's requirements for admission. Those with symptoms related to substance abuse may be referred to appropriate services, and others who are deemed not to be a danger to themselves or others are handed off to outpatient providers, Varton said.

Schlaepfer said some law enforcement agencies take people placed on psychiatric holds directly to a county emergency team next to the Psychiatric Health Facility in Ceres, where some can be stabilized without hospitalization. The county expects to open a crisis stabilization unit there in February, providing a quiet atmosphere and adjusted medications for those with less severe symptoms.

Memorial Medical Center in Modesto has seen almost a fivefold increase in people seeking emergency attention for psychotic episodes. The number of ER visits climbed from 111 in 2012 to 383 in 2014. The hospital expects a total of 500 this year.

Scott Baker, who manages the emergency department, said patients are assessed by county mental health personnel and those with insurance are transferred to Doctors Behavioral Health Center. The uninsured and Medi-Cal recipients are sent to the county facility in Ceres.

Baker said he believes the local system is better equipped now to handle those who truly need care.

"I don't think anyone is held for more than 10 to 12 hours," Baker said. "The difference now is we have more resources in the community."

Ken Carlson: 209-578-2321

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