Consultants lay out problems with county mental health care, advise costly fixes.

On Dec. 14, 2012, the unthinkable happened at Sandy Hook Elementary School in Newtown, Connecticut. Twenty-year-old Adam Lanza shot and killed his mother, 20 schoolchildren and six others before killing himself.

The nation mourned – and grappled with questions of how the disturbed young man might have avoided violence. One effect was to elevate awareness of the need to get people mental health care, according to Wayne Clark, executive director of the California Mental Health Services Authority (CalMHSA).

“The shooting in Newtown has increased awareness that we need to help our isolated, alienated individuals,” Clark says. “Unfortunately, [those patients] come to our emergency systems, which are overloaded and which don’t have enough access.”

Two recent reports by outside consultants look at that problem of overloading. They show the county Behavioral Health Department is failing to keep up with many mentally ill patients in need, and that shoddy record-keeping isn’t helping.

For 12 years, Clark was with the Monterey County Health Department, where he led the Behavioral Health Department through big growth before taking the helm of CalMHSA last month.

During Clark’s tenure at the county, the department’s budget for treating mental illness and substance abuse tripled. Meanwhile the number of patients more than doubled: Beginning in the fall of 2013, the average daily census of inpatient mental health clients jumped from about seven to about 16.

“We thought it was just a spike, but it seemed to sustain itself for the last year and half, and continues to,” Clark says. He attributes that to Newtown and to expanded insurance coverage under the Affordable Care Act.

But the spike has left the county Behavioral Health Department struggling to keep up. It’s also shed light on some deeper problems with staff morale and basic record-keeping.

County Health Department Director Ray Bullick decided to call in outside consultants last fall.

“A number of allegations have been raised relative to Monterey County Health Department Behavioral Health,” Bullick wrote in an Oct. 22 memo to top behavioral health officials. “These concerns potentially impact client services, employee job satisfaction and our ability to properly provide services.”

The consultants’ findings were circulated in two draft reports to behavioral health staff Feb. 25.

“Overall, it appears that clients are getting good care,” wrote Dr. Marshall Lewis, a professor of psychiatry at UC San Diego Medical School. “However, there are significant deficiencies in charting.”

He then lists the glaring ones, based on a review of patient charts. “Only six of 30 charts had evidence of reasonably complete evaluations,” Lewis reported.

Only two of the 30 charts reflected a safety plan if clients had suicidal or homicidal thoughts, and only 17 showed whether clients had been previously hospitalized for psychiatric treatment. Of 12 clients with addictions, only three had recorded recovery plans.

“It’s clear that current screening for alcohol and substance abuse and referral for treatment are inadequate,” Lewis wrote.

His biggest concern was behavioral health providers’ slow response to primary care providers. He identified three high-risk patients who were never successfully referred into the behavioral health system.

One was a man diagnosed with depression and a history of “rage attacks or blackouts,” as well as hallucinations. He was referred by a primary care provider to a mental health clinic March 14, 2014, but never admitted.

In another instance, a homeless woman recently arrested for methamphetamine possession was not monitored for substance abuse, despite being treated with a narcotic for pain. A primary care clinic referred her to a mental health setting Oct. 11, but she was never admitted.

The second report, focusing on access to care and prepared by business consultant Ezequiel Vega, looked at long wait times for patients to get appointments. From 2013 through 2015, the average wait time among 2,527 patients was 86 days.

Vega also found an inconsistent intake system, and a troubling tendency to recommend non-crisis patients return for “walk-in Wednesdays.”

Like Lewis, he also took issue with the referral and intake system. “There is a system in place to track referrals to Behavioral Health services; not all clinics are following it consistently,” he wrote.

To address these problems, Vega recommended investing $3 million to hire more staff and streamline intake systems. He proposes redesigning the department’s website and scheduling appointments within 14 days of a patient’s request.

Bullick’s proposed fix: hiring 31 new behavioral health clinicians, including 26 social workers and two physicians. The County Board of Supervisors voted 5-0 March 17 to approve the staff increase at a cost of $750,000.

In moving to approve the positions, Supervisor Dave Potter said, “The heavy lifting is still ahead of us, but I believe you’ve laid out a pathway to success.”

Bullick says his team will begin recruiting soon, after they’ve given internal candidates the opportunity to apply for the newly created jobs.

“This will go a long way to fix the problems,” Bullick says, “but there’s still a new culture we need to develop. We have a ways to go from, ‘This is what we are mandated to do to ‘We are going to provide service to everyone.’”