Hospital director weighs in on Santa Cruz County mental health services

Nov. 17--LIVE OAK -- In an effort to provide further context to the Oct. 16 officer-involved shooting of Sean Arlt, the National Alliance on Mental Illness of Santa Cruz County invited Michael Fitzgerald, director of Behavioral Health Services at El Camino Hospital, to discuss the problems around mental health care and access Wednesday night at the Live Oak Senior Center.

Fitzgerald is a lifelong Santa Cruz County resident who has worked in mental health since the late 1970s, including at a mental health facility in Santa Cruz beginning in 1981. In those days, Fitzgerald said, there were enough beds locally to treat those with significant mental illness conditions.

Although some patients were treated for long periods without improvement and transferred to a state institution, most did get better. They were placed in residential facilities and eventually returned to their families, Fitzgerald said.

So what happened? Several complex economic factors contributed to the downfall of the mental health system in California, according to Fitzgerald.

Inflation created skyrocketing costs. As a result, psychiatric hospitals became private, for-profit enterprises. Eventually the insurance companies partnered with managed care companies to keep costs even lower. In the 1990s, the state changed the funding streams for mental health in a two-step process of realignment and capitation.

Corporations stepped into the market because they could provide mental health services for even less. The Psychiatric Health Facility, or PHF, proliferated. The PHF, pronounced "puff," started out as a low cost mental health solution for rural areas before appearing in cities. The Santa Cruz PHF is run by the Telecare Corporation.

"PHFs have very low regulations, they are exempt from high facility costs and they can't treat anyone who needs hospital-level care. As a result, their staffing requirements are low. They don't pay well and they're not unionized," Fitzgerald said. "They also can't have more than 16 beds."

The PHF's metrics are based on length of stay and remission rate. As a result, Fitzgerald said, PHFs are incentivized to release patients early and not re-admit them.

Just as important is the fact that the Santa Cruz County community has developed a higher tolerance for the seriously mentally ill.

"As a community, we've decided it's OK to have these people screaming and crying and openly eating garbage or whatever in our streets," Fitzgerald said. "That is a choice we've made."

By opting to limit the number of beds and services available, the U.S. has traded one institution for another, Fitzgerald said. "The largest mental health facility in the nation is Los Angeles County Jail -- followed closely by Cook County Jail and Riker's Island," Fitzgerald said. "The decline of psychiatric beds is a perfect correlation with the number of seriously mentally ill people we incarcerate."

Unfortunately, a leadership void in the mental health community exists. Namely, the state of California has no agency addressing the problem, Fitzgerald said. The issue is addressed entirely at the county level.

"Somebody once said, 'Every system is perfectly designed to achieve the results that it gets.' The death of Mr. Arlt, the killing of Shannon Collins and many other horrid events -- as well as the daily tragedy of our downtown streets and parks -- were unintended consequences but predictable outcomes of all the things I've mentioned. It was a conspiracy of incentives and mis-incentives."

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