Two state bills could help San Francisco address major gaps in care for its public behavioral health clients, including more than a dozen psychiatrist vacancies and capacity issues in regard to treatment beds.
Assembly Bill 565 would broaden the pool of aspiring community psychiatrists eligible for debt relief to address a growing national psychiatrist shortage that has left one of four psychiatrist positions chronically vacant statewide. Assembly Bill 682 requires the state health department to apply for funds to create a real-time psychiatric bed registry.
Both bills are sponsored by the California Psychiatrist Association (CPA) and were voted out of the Assembly Health Committee last month. Supporters say that they could offer some relief locally, where retention and recruitment of qualified psychiatrists as well as a shortage of “step down” care beds are an issue.
“We need psychiatrists for treatment, we need beds for treatment, they go hand in glove. Both of these proposals attack the issue from different perspectives,” said CPA Director of Government Relations, Randall Hagar, who added that the bills “are by no means final solutions, but they will help.”
The San Francisco Public Health Department currently employees 75 psychiatrists, but has struggled to fill another 17 chronically vacant psychiatrist positions.
“There are just not enough psychiatrists, there is a huge shortage and its a bigger issue,” the health department’s newly instated director, Dr. Grant Colfax, told the San Francisco Examiner, adding that the department is currently grappling with ensuring that “we provide not only the right care to the right people at the right time [but] making sure that the right people are providing the right care at the right time.”
Significant student loan debt, coupled with an increasingly high cost of living, particularly in San Francisco, have pushed seasoned psychiatrists as well as those in training away from the public sector and into private hospitals.
Mark Leary, interim Chief of Psychiatry at Zuckerberg San Francisco General Hospital and Trauma Center, which is staffed by UCSF psychiatrists, said that “there have been a number of people in recent years who have left and gone to Kaiser,” adding that it’s a “constant struggle to keep good psychiatrists” in what he described as a “competitive market.”
Under AB 565, any employee working for a county mental health department would be eligible for loan repayment under the Steven M. Thompson Physician Corps Loan Repayment Program, which offers $35,000 annually for three years.
Hagar, of the CPA, said the bill could have “huge ramifications in retention and recruitment” for public hospitals across the state, including at ZSFGH.
“I think it takes a special kind of person to think about public service in the first place.We want people to start thinking about that [route] early on in their careers,” said Hagar, adding that “the debt burden of anyone who trains… is exceedingly high compared to what it was a decade ago.”
Aneesh Nandam can attest to this dilemma; the UCSF psychiatry resident is shouldering nearly $300,000 in student loan debt.
“I’m somebody who always wanted to work in the public sector. If there was a student loan forgiveness in California for working in the public sector that makes it all the more easier for me to make that decision,” said Nandam. “Kaiser and other places pay really well. That’s a consideration when you are walking around with several hundreds of thousands of dollars of debt.”
Approximately two-thirds of San Francisco’s homeless population suffers from a mental, physical or substance abuse disorder or a combination of the three, according to a recent point-in-time count. These clients in particular bear the brunt of a system that is expensive, complex and chronically at capacity.
Local health officials have pointed to a growing need for investments in intermediate care — including bolstering The City’s stock of subacute and residential behavioral health beds where clients leaving acute inpatient care may continue their recovery.
Psychiatric care providers complain that they often have nowhere to send clients after they graduate out of acute inpatient care but need further treatment, while city health officials report a “bottleneck” in the continuum of care due to a lack of appropriate placements in the community.
While funding for additional beds remains an issue, an online, real-time behavioral health bed registry as mandated by AB 826 could help The City identify gaps in services and areas where investment is needed, said Hagar.
“This online registry [would] utilize technology to tell you where there are beds that are potentially appropriate for your patient…and find matches in a much more expeditious manner than cold calling a bunch of facilities on a list,” he said.
In her nearly three decades of employment at the public hospital, Meg Brizzolara, a psychiatric nurse at ZSFGH said she has seen the hospital’s four psychiatric units, which in 2008 had 87 beds, shrink down to two units — one for acute inpatient care and one used as a subacute “step down” unit, with a combined 44 beds. The hospital also has a 12-bed unit for behavioral health clients who are in custody.
“Psychiatric Emergency Services has a revolving door of people they discharge from there or admitted to the inpatient unit, where they are discharged too soon, then they relapse and come back,” Brizzolara said.
While some patients are released too soon, others remain in acute care for longer than prescribed, because placements at residential care facilities or in subacute settings are simply not available.
“What happens is people end up coming in for acute care at the hospital but once their acute symptoms have resolved and they are ready for discharge to a lower level of care and get voluntary treatment rather than in a locked setting, we don’t have the beds to be able to transfer them,” said Leary. “So they end up staying and waiting on subacute beds, backing up the system.”
Leary said that investing in additional subacute and residential treatment beds makes sense, because acute beds are “by far the most expensive beds in the system.”
The number of DPH contracted facilities has dropped from 70 to 37 in the past five years, according to Kagan. The department currently works with 61 board and cares, combining in and out of county facilities. But those too are dwindling, she said.
Overall, the city has a current inventory of 2,000 behavioral health beds — from crisis to acute inpatient care, residential treatment beds and board and cares — at public and private hospitals, according to Kagan. Including the beds at ZSFGH, The City currently has a total of 132 inpatient psychiatric beds.
San Francico’s 394 residential substance use and mental health treatment beds are operated by, HealthRight360, Progress Foundation, the Salvation Army and other community providers.
Kagan said that The City has been investing in expanding the behavioral health system, with Mayor London Breed having publicly committed to adding 100 beds by next year. Some 72 of those will be step down beds for substance abuse treatment operated by Healthright360 on Treasure Island, pending allocation of funding.
She added that the city has increased funding for “board and cares,” or smaller assisted living facilities, by $1 million in 2017, with an Assisted Living Working Group studying the need.
Breed also appointed former ZSFGH Psychiatric Emergency Services medical director Dr. Anton Nigusse Bland to a new leadership position within DPH to make changes to the behavioral health system as director of mental health reform.