At the acute end of the mental health care spectrum in California, contraction and reorganization are changing the way public and private hospitals care for patients.
At the other end of the spectrum, where a recent report shows that many Californians who need mental health care aren't getting it, community and local providers are cautiously optimistic that treating less acute mental health problems may get easier.
What's happening at the acute end of the spectrum is directly connected to some of that optimism at the other end. A major overhaul of the way California deals with mental health is underway, partly in response to safety issues at mental hospitals, partly in response to Department of Justice oversight, partly in anticipation of federal health care reform and partly because of a major realignment shifting management and funding for many mental health services from the state to counties.
A significant part of the overhaul was announced this week: State officials want to establish a new Department of State Hospitals to replace the Department of Mental Health. The new department will oversee five state mental hospitals and psychiatric treatment at two state prisons. The proposal calls for higher staffing ratios at facilities with sicker and more aggressive patients and lower ratios for hospital units with more stable patients. The state is installing a new alarm system at Napa State Hospital, where a patient killed a psychiatric technician last year.
State officials said they do not expect proposed changes to interfere with DOJ oversight that has been in place for more than five years as part of a settlement of a lawsuit over patient treatment.
Although state officials did not characterize the reorganization as a contraction, the plan calls for eliminating 600 jobs, on top of 600 previously eliminated jobs.
Private mental health care providers also are cutting back. Last week, Cedars-Sinai Medical Center in Los Angeles announced plans to close its inpatient and outpatient psychiatry programs. Cedars-Sinai has 51 beds for mental health patients.
Mental health acute care services have declined in both public and private hospitals over the past couple of decades.
A report by the Treatment Advocacy Center, a mental illness advocacy organization based in Virginia, showed that only one out of the 20 public psychiatric beds that existed in the U.S. in 1955 were still around by 2005. California has about 6,300 inpatient psychiatric beds at its five state mental health hospitals.
Private facilities in California have about 6,500 acute care inpatient psychiatric beds, down from about 8,500 in 1996, according to California Hospital Association statistics.
Part of Larger, Long-Term Trend
The reduction of inpatient services in California is part of a longstanding trend away from institutionalization.
"The goal is to serve people in their communities, not in institutions," said Patricia Ryan, executive director of the California Mental Health Directors Association, which represents mental health directors from each of California's 58 counties.
The realignment of mental health management and funding is part of that trend.
"Overall, there are huge things happening in community mental health -- structural changes and opportunities we view positively," Ryan said. "A lot of good things can come of these changes. There is never enough funding, but there are a lot of positive changes."
Realignment is aimed at creating a more coordinated approach to mental health care by shifting funding and management from the state to counties, which have had most of the responsibility for non-acute mental health treatment for many years.
The larger reorganization -- of which realignment is a part -- includes the possibility of new state agencies, such as the recently announced Department of State Hospitals. The reorganization is funded in part with money from Proposition 63, a ballot measure passed in 2004 that levied a tax on Californians with annual incomes above $1 million to raise money for mental health services.
'Things Will Get Better'
For community providers of mental health services in California, change can't arrive too soon.
Researchers at the UCLA Center for Health Policy Research released a report last week showing that nearly two million Californians say they have mental health conditions that require treatment, but most of them do not receive the care they need.
UCLA researchers recommend that mental health care be integrated into general health care, suggesting that primary care physicians routinely screen patients for mental health problems and provide referrals to mental health specialists.
While mental health care providers aren't expecting to become part of the medical mainstream anytime soon, many in California are expecting improvement.
"I think there is a sense that things will get better," said Rusty Selix, executive director of the California Council of Community Mental Health Agencies. "In many ways, conditions are horrendous and difficult, but we're kind of used to that."
In addition to realignment, many mental health professionals -- including Selix -- expect changes in the Affordable Care Act to improve mental health treatment options.
Selix, who also is executive director of the California chapter of Mental Health America, said people in acute care hospitals are "in a different world" than people in outpatient settings.
"What we all have in common though is living in the same economy. When the economy is bad, demands for services go up and ability to pay for them goes down. That causes stress levels to go up," Selix said.
"But I think the economy is starting to come back a little and that will help all around."