[Noozhawk’s note: This article — part of a Noozhawk special project in partnership with the USC Annenberg Center for Health Journalism — is the first in a series investigating the shortage of acute care psychiatric beds for people experiencing a mental health crisis in Santa Barbara County. Noozhawk recognizes that mental illness and the challenges of navigating the mental health system are vulnerable experiences to share. Pseudonyms are being used for two of the local residents in this story, at their request.]
Jim was diagnosed with paranoid schizophrenia when he was 15 years old.
Over the past two decades, the Orcutt resident has bounced around Santa Barbara County’s Department of Behavioral Wellness clinics, emergency room departments, and psychiatric hospitals as far away as Pasadena to receive the care that he needed to manage his diagnosis.
Jim experienced another psychotic break in the winter of 2021 and could not get in touch with his practitioner at a Behavioral Wellness clinic in Santa Maria.
“My son just started decompensating,” said Alice, Jim’s mother who lives in Goleta.
Jim’s stay in the emergency department was so long because Santa Barbara County did not have an acute inpatient bed to release him to.
His situation is not unique.
Santa Barbara County only has 16 psychiatric acute inpatient beds for patients at its Psychiatric Health Facility at 315 Camino del Remedio in Santa Barbara. The facility operates at almost maximum capacity every single day, according to John Winckler, division chief of clinical operations at the Department of Behavioral Wellness.
Any facility with more than 16 beds is classified differently and excluded from Medi-Cal reimbursement, making care in those larger facilities cost twice as much without that federal match, according to the California Department of Health Care Services.
The lack of available mental health acute inpatient beds in Santa Barbara County not only strains hospitals’ emergency departments because of the extreme lengths of time the patients need to be held before they are discharged in a safe manner, but it also keeps those patients from receiving the critical acute care that they need.
A 2021 assessment of behavioral health services in California ranked Santa Barbara County sixth among 58 counties with the largest gap between the number of existing psychiatric inpatient beds and the number of beds needed.
The report found that the county only has less than 40% of the beds needed to care for its population: 16 available beds and 43 needed beds.
“More than half of the counties (38) reported needing additional acute inpatient hospital services (e.g., psychiatric acute care hospitals or acute care psychiatric units) for adults,” according to the Department of Health Care Services report.
“Seventy percent (42 respondents) identified an urgent need for this service for children and youth.”
People are placed on 5150 holds if they meet at least one of the following criteria: the person is a danger to him or herself, the person is a danger to others, or the person is gravely disabled by their mental illness.
When someone is placed on a 5150 hold at county hospitals, they stay in a holding phase until the 5150 is either rescinded after 72 hours or the person is transferred to an inpatient psychiatric treatment bed. There are also 5585 holds, which are similar involuntary psychiatric holds for juveniles.
Nearly 10% of the holds written at Santa Barbara Cottage Hospital between January and November 2021 expired because placement at a locked psychiatric health facility was not available, according to data obtained by Noozhawk. The hospital reported 952 involuntary patients during that time period, with a monthly number between 69 and 119 people.
The average length of stay for patients in Cottage Hospital’s emergency department holding unit in 2021 was 24 hours, an increase of 33% from 2019.
“If a patient is waiting 22-23 hours to get a bed, and we don’t have any other diagnoses for that patient, they wait that long because of the lack of (acute inpatient) beds in the county,” Darcy Keep, administrative director of psychiatry and addiction medicine at Cottage, told Noozhawk.
Santa Barbara County is the only county in California where law enforcement officers cannot place someone on a 5150 hold — someone from the Behavioral Wellness Department’s mobile crisis team must come and evaluate the person to place the hold.
It is not unusual to wait several hours for a mobile crisis team to arrive to do the evaluation, further lengthening the time that acute mental health patients are stuck in emergency room departments waiting for secure placement, according to Dr. David Ketelaar, an emergency medicine physician at Marian Regional Medical Center in Santa Maria.
“Once you make the determination that they need to be on a hold and you evaluate them physically, when beds aren’t available, you hold them until appropriate care is available,” Ketelaar told Noozhawk.
“It makes you lose the capacity to accept a new person in the emergency room.”
The average emergency room visit for someone who comes in for pneumonia, a broken arm or other physical conditions is around two to four hours at Marian Regional Medical Center, but the average length of stay for someone on a 5150 hold is 37 hours, according to Ketelaar.
Roughly 30% of the patients on hold at Marian in November 2021 had their holds rescinded and were sent home, he said.
The average length of stay for those patients was 42 hours, but the stays ranged from 14 to 124 hours.
The person who was held the longest had to stay in the emergency department for more than five days.
The average length of stay for patients undergoing mental health evaluations at Marian in 2017 was 27 hours, and that number has been increasing incrementally over the past four years, reaching 31 hours in 2021, according to data obtained by Noozhawk.
“That tells me that the problem is getting worse, no matter what everybody is doing,” Ketelaar said. “The system is collapsing around us.”
Of Marian’s patients who were successfully sent to Santa Barbara County’s Psychiatric Health Facility in November, it took on average of nearly three days to get them there, according to data obtained by Noozhawk.
“I’ll be happy when that number is down to 10-12 hours,” Ketelaar said.
What’s Next in the Series
This report is the first in Noozhawk’s series analyzing Santa Barbara County’s acute care beds for mental health patients in crisis.
The next article will be published April 26 and will investigate where local residents are sent for care when the county does not have available space at its Psychiatric Health Facility in Santa Barbara — and how much sending patients to out-of-county facilities costs the county.
This series is produced as a project for the USC Annenberg Center for Health Journalism’s 2021 Data Fellowship.