Psychiatric Emergency Services in Los Angeles County

Christina Ghaly, MD Deputy Director, Strategic PlanningDepartment of Health Services

July 26, 2012

Roderick Shaner, MDMedical DirectorDepartment of Mental Health

Outline•Evolution of PES services in LAC•Problem Statement•Overview of Challenges and Potential

Solutions•Data•Initiatives•Discussion

Evolution of LAC MH Crisis Services • Division of responsibilities for emergency

services in 1978▫Hospital-based Psychiatric Emergency

Services: DHS▫Psychiatric Mobile Response Teams: DMH▫Payment and Coordination mechanisms: Vague

• Creation of DMH Emergency Outreach Bureau 2000

• Development of Alternative Crisis Services 2006

4

5

Problem Statement•A variety of acute and longstanding

challenges lead to PES overcrowding•We must intelligently identify and

implement effective and practical solutions to these challenges in order to ensure high-quality crisis mental health services in LA county

PES Challenges and Potential Solutions• Divided responsibilities: Integration of procedures for

relevant agencies• Legal issues regarding involuntary treatment: Re-

evaluation of procedures for detention, detainee transport, LPS conservatorship

• PES over-use: Alternative crisis services: UCCs• Inpatient over-use: Changes in PES and inpatient

internal processes, develop alternative residential approaches

• Concerns about insufficient capacity: Develop consensus on PES and inpatient missions

• Funding restrictions: MHSA changes

Age distributionPercent of Patients, FY2007-11

8

  Harbor LAC+USC Olive View DHS Overall

Age 0-12 1 2 1 1

Age 13-17 6 9 10 8

Age 18+ 93 89 89 91

GenderPercent of patients, Calendar Year 2011

  Harbor LAC+USC Olive View

DHS Overall

Female 41 37 39 39

Male 59 63 61 61

9

Harbor and Olive View: all patients; LAC+USC: adults only

Mode of ArrivalPercent of patients, 2011  DHS Overall

Law enforcement 54

Self/family/friends 24

Ambulance 10

DMH / PMRT 9

Jail/ Juvenile Hall/ State prison

1

Other 2

10

Harbor and Olive View: all patients; LAC+USC: adults only

  Harbor LAC+USC Olive View DHS Overall

SPA 1 1 1 8 3SPA 2 4 4 61 18SPA 3 4 17 3 9SPA 4 7 36 3 18SPA 5 5 2 1 3SPA 6 22 14 2 14SPA 7 7 12 1 8SPA 8 36 3 2 14Unknown/missing

14 11 19 13

Total 100 100 100 100

SPA of residencePercent of patients, Calendar Year 2011

11

Harbor and Olive View CY2011; LAC+USC CY2010; unknown/missing includes out of County and homeless

  Based on Primary Diagnosis ICD-9 code (1)

    Chief Complaint at time of PES arrival (2)

Affective Psychoses

26 Depressed/ suicidal

47

Other Nonorganic Psychoses

24 Bizarre/ agitated behavior

17

Depressive Disorder

8 Aggressive/ violent

15

Schizophrenic Disorders

5 Acute/ chronic psychosis

10

Neurotic Disorders

2 Grave disability

3

Other 35 Other 8

Primary diagnosis / Reason for visit Percent of Patients, DHS overall, CY 2011

12

[1] Harbor and Olive View CY2011; LAC+USC CY2010[2] Harbor and LAC+USC Oct/Nov 2011; OVMC CY 2011

Addressing overcrowding in the PES

13

Program development / process improvements• Further invest in intensive case management programs

for individuals that frequently utilize the PES• Streamline access into substance abuse rehabilitation

programs• Improve coordination with DCFS• Increase DMH liaison activities • Engage with LPS-designated individuals regarding

appropriate use of 5150 holds and range of potential destinations to which patients on holds may be transferred

• Educate psych inpatient and PES staff to more rapidly discharge patients to open community-based facilities

• Develop Post-hospitalization Placement Problem Comm.

14

Program dev. / process improvements – con’t• Address operational issues that delay timely patient

throughput▫ Supplement social service staff▫ Streamline ambulance crew drop-offs▫ Streamline Hawkins discharge procedures▫ Pilot adolescent transfer protocols▫ Promote linkage with DMH FSPs

• Reduce, where appropriate, interfacility variation in clinical practice patterns

15

PES Outcomes Study – DMH/DHS Collaborative Effort• Study Aims:

▫ Describe the demographic, social, and clinical factors of PES pts

▫ Identify predictors associated with discharged vs. admitted PES pts

▫ Compare longitudinal outcomes of discharged vs. admitted PES pts

• Study Design:▫ Retrospective cohort of adult LA County residents seen in

one of three LAC locked PESs from 2008 through 2010▫ Longitudinal utilization and clinical outcomes traced from

2008 through 2011

16

PES Outcomes Study – Data sources

17

DHS – Affinity • Baseline demographic, insurance, hold status, psychiatric/medical diagnoses, etc.

• Subsequent medical ED visits and medical hospitalizations at DHS hospitals

Sheriff – Automated Jail Information System (AJIS)

• Booking information, arrest offense code, release date, housing location, etc.

DMH – IS • Outpatient mental health care visits, PES revisits, inpatient psychiatric admissions, PMRT contacts, forensic mental health episodes

Coroner’s Database

• All adult decedants, including mode of death, location of death, diagnoses at death

Data infrastructure• Continue efforts to establish a Unique Patient

Identifier within DHS and a County Master Patient Index

• Monitor progress on placing “difficult to place” patients through systematic data collection efforts

• Continue to monitor trends in PES utilization by AB109 releasees and, in collaboration with CDRC, develop strategies to divert inappropriate visits as needed

18

Expand non-PES hospital capacity• Implement DHS Supportive Housing program• Investigate 23-hour holding unit for DCFS children within the

Children’s Village at LAC+USC• Maximize use of Olive View Urgent Community Services

Program by obtaining LPS designation; investigate 24/7 feasibility

• Investigate alternate UCC sites (e.g., MLK)• Pursue development of a joint DHS/DMH SNF contract• Open vacant 5-bed unit at Augustus Hawkins• Expand Psychiatric Diversion Program • Invest in community-based residential facilities such as

crisis residential beds and acute diversion units• Build capacity/capabilities at Juvenile Halls/Camps (e.g.,

acute stabilization unit, step-down intensive day-treatment unit)

19

Improve adequacy of existing PES facilities

20

21

Summary of new PES investments in FY12-13 budget

  2012-13 2013-14DHS DMH DHS DMH

1. ** Olive View PES Expansion 4.0 -

-

-

2. * Expansion of Olive View UCC - 0.5 - 1.13. * MLK– Augustus F. Hawkins UCC - 2.7 - 5.54.1 * 1.0 Psych SWII - 0.1 - 0.14.2 ** Additional acute inpatient beds - 2.1 - 2.15. ** 2.0 Deputy Public Conservator - 0.2 - 0.26. ** 40 Additional IMD beds - 2.8 - 2.87 . * 11 Additional IMD step-down beds - 0.6 - 1.1

8. ** 1.0 Child Psychiatrist at Harbor 0.3 - 0.3 -

Total

4.3

9.0

0.3

12.9

* MHSA - Eligible

-

3.9

-

7.8

** NCC Required 4.3

5.1

0.3

5.1

Discussion and Final Comments

PES Average Daily Census and Implementation of PES Relief Measures FY2004 – 07

23

20

30

40

50

60

70

80

90

100

Avg Census 68.4 75.1 70.2 70.9 65.6 65.3 76.2 82.0 78.2 73.3 70.4 71.3 76.6 74.1 69.7 68.3 67.3 61.5 66.4 66.3 60.7 68.0 69.9 72.0 75.5 70.4 61.7 71.0 63.4 41.5 41.5 44.7 52.0 47.5 46.6 46.1

Jul-04

Aug-04

Sep-04

Oct-04

Nov-04

Dec-04

Jan-05

Feb-05

Mar-05

Apr-05

May-05

Jun-05

Jul-05

Aug-05

Sep-05

Oct-05

Nov-05

Dec-05

Jan-06

Feb-06

Mar-06

Apr-06

May-06

Jun-06

Jul-06

Aug-06

Sep-06

Oct-06

Nov-06

Dec-06*

Jan-07

Feb-07

Mar-07

Apr-07

May-07

Jun-07

Implementation of Urgent Care Center (UCC) at AFH

11/04

Private Hospital – DHSTransfer Program 2/05

DMH PES Liaisons 3/05

12 child and adolescent beds 4/05

DMH Inpatient Liaisons 11/04

Anne Sippi Clinic: 20 adult beds 5/05

Crisis Residential Services at OVMC 5/05

Implementation of UCC at Olive View Medical Center (OVMC) 5/05

Kedren Community MHC: 11 adult beds 6/05

24 Hour UCC services at AFH MHC 6/05

Cedar Street Residential Program: 38 adult beds 7/05

College Hospital-Cerritos: 2 adult beds 8/05

White Memorial Medical Center: 8-10 adult beds 8/05

Implementation of Psychiatric Diversion Program (PDP) 8/05

Gateways Residential Program (Percy Village): 48 adult beds 10/05

Countywide Resource Management takes

over PDP 11/06

AFH PES closes 12/06

Implementation of Westside UCC 12/28/06

Increase in coverage hours to 9:00PM Monday through Friday at OVMC UCC 12/06

10 additional beds for DHS 12/06 to 2/07

Gateways Residential Program (Percy Village II): 25 adult beds 4/07

SSG Residential Program: 25 adult

beds 4/07

Gateways Residential Program (Normandie Village): 42 adult beds 4/07

Telecare Residential Program: 25 adult

beds 4/07

PES Average Daily Census and Implementation of PES Relief Measures FY2007 – 10

24

20

30

40

50

60

70

80

90

100

Avg Census 46.2 46.5 45.4 44.2 37.9 37.9 42.1 49.9 53.4 48.9 49.0 49.9 47.9 46.6 53.7 50.8 43.6 43.3 49.3 48.3 48.5 46.5 47.0 45.0 53.5 50.9 54.8 51.6 49.3 40.4 46.4 43.9 54.5 43.5 48.2 51.5

Jul-07

Aug-07

Sep-07

Oct-07

Nov-07

Dec-07

Jan-08

Feb-08

Mar-08

Apr-08

May-08

Jun-08

Jul-08

Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

Mar-09

Apr-09

May-09

Jun-09

Jul-09

Aug-09

Sep-09

Oct-09

Nov-09

Dec-09

Jan-10

Feb-10

Mar-10

Apr-10

May-10

Jun-10

Olive Vista: 70 Forensic IMD adult beds 8/07

Reduced hours at AFH UCC 9/07

Kedren Community MHC: 18 adult beds 9/07

Gateways Residential Program (Percy Village II): 25 additional adult beds 3/08

Countywide Resource Management – Specialized Housing Program 11/07

Gateways Residential Program (Gateways Satellite):

17 adult beds 11/09

Social Model Recovery Residential Program (River

Community): 16 adult beds 1/10

BRIDGES Residential Program (Casitas Esperanza): 14 adult

beds 1/10

Health Research Association Residential Program: 12 adult beds 2/10

Eastside Urgent Care Center (Serves 50-60 persons per day) 4/10

Voluntary Assisted Outpatient Program: 10 adult beds 4/10

PES Average Daily Census and Implementation of PES Relief Measures FY2010 – 12

25

LAC+USC Medical Center Needs Special Assistance

Program (30 housed) 10/10

SSG Special Needs Residential Program: 30 adult beds 10/10

Southern California Alcohol & Drug Program Residential Program (Hearing Impaired): 5 adult beds 11/10

Olive View UCSP opens new facility

(7 days per week) 8/11

Child/Adolescent Services at Eastside UCC (capacity: 6 persons) 4/11

20

30

40

50

60

70

80

90

100

Avg Census 53.9 57.9 50.8 54.5 53.5 42.9 51.1 48.6 47.2 50.8 56.1 46.5 52.5 57.1 58.9 57.2 50.9 47.1

Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11

View Heights IMD: 40 adult beds 8/11

Telecare IMD Step-down: 25 adult beds 11/11