San Diego County officials have until October to stand up a new system to compel people with certain serious mental illnesses into treatment.
There’s a lot to do before then, and among the many challenges the county is up against is an undeniable obstacle: Though the program is only expected to serve a relatively small group of people, it’s likely to hammer a system that already regularly fails to deliver the right care for those who need it.
Background: Last year, Gov. Gavin Newsom and state lawmakers backed the creation of the Community Assistance, Recovery, and Empowerment Court – better known as CARE Court – which will allow family members, friends, health care providers and law enforcement to petition California courts to order care for people with untreated schizophrenia or other psychotic disorders.
It’s up to each county to investigate the person’s condition, and based on that evaluation, the courts will decide whether the candidate is a fit and to order a treatment plan for care.
The controversial state edict reflects a decades-long debate that has ratcheted up along with a recent rise in homeless Californians who appear to be languishing on the street. State officials decided courts, families, and officials needed more power to require people with serious mental illnesses to get care. It’s a population long ago served in mental institutions and later meant to access community-based treatment. Many activists oppose CARE Court.
While some leaders have touted CARE Court as a panacea for homelessness, it’s not clear what percentage of people the initiative serves will even be homeless. The number of people the county expects it to serve isn’t massive given its narrow focus on certain psychotic disorders. Yet it’s still going to be a herculean task for the county to serve CARE Court patients given the overburdened healthcare system it’ll be relying on – and if it can’t deliver that civil court-ordered care, it could face fines of up to $1,000 a day.
For now, the county’s behavioral health services director said the county roughly estimates it will receive about 1,000 petitions a year and that a judge will determine about 250 of those patients qualify for treatment. A Superior Court judge overseeing implementation of the new court system expects one of the court’s divisions to handle CARE Court petitions two days a week on top of its existing workload.
As the county hurries to make sure it can serve these patients, there is a lack of clarity, even among insiders, on how CARE Court will work and whether the already-struggling system can handle the new state mandate — just weeks before the county’s October deadline. Longstanding challenges remain with providing people with mental health conditions access to multiple levels of care due to inequities unique to the behavioral health system, workforce shortages and more. More long-term care beds are needed to house CARE Court participants, but there is a county-wide shortage. Some stakeholders are also raising concerns about whether the plan violates civil liberties.
“The core problem in my mind is there’s nowhere to go – no infrastructure – so it’s sort of the cart before the horse,” said Jerry Gold, behavioral health administrator at Scripps Health, who says he hasn’t received enough details on how the process will work. “You need to build the infrastructure before you build programs like this.”
The Current State of the System
Psychiatric social workers Carrie Dillon (left) and Jacqueline Rivera (right) work at Sharp Mesa Vista Hospital on Sept. 20, 2022. They are tasked with finding step-down placements for patients who need additional care after they leave the hospital. / Photo by Ariana Drehsler
County data obtained by Voice of San Diego reveals the breadth of the county’s challenge. The number of days that adult behavioral health patients with Medi-Cal insurance spent waiting in hospital beds for post-hospital care has surged in recent years – and was spiking even before the pandemic.
The numbers: From July 2022 through May 2023, patients collectively spent more than 16,000 days waiting in hospital beds regionwide after doctors decided they were ready to be discharged to a lower level of care. From July 2022 through May 2023, patients collectively spent more than 16,000 days waiting in hospital beds regionwide after doctors decided they were ready to be discharged to a lower level of care.
Many of those lower levels of care are the very residential treatment services the county expects many CARE Court patients to need – and existing demand and waits for them have long wreaked havoc on the rest of the system. CARE Court will put even more pressure on the region’s limited options.
County data shows behavioral health patients in hospitals waited an average of 43 days for a bed in longer-term care facility in the past year.
For patients, these waits can be demoralizing and sometimes result in backslides from what had been improving health conditions.
Luke Bergmann, the county’s behavioral health services director, acknowledges that a slew of challenges – from workforce needs to infrastructure challenges – complicate the county’s ability to quickly deliver new beds and thus stem those wait times.
The County’s CARE Court Plan
The county will receive $44.3 million in state grant funds to support housing investments for people with behavioral health conditions. The plan is to bolster board-and-care offerings, which typically assist residents with medication and meals.
This category of housing — long considered crucial for people with serious mental illnesses — has been a shrinking resource in San Diego and statewide. Bergmann believes these homes will be a crucial landing place for CARE Court participants to stabilize, but the county has estimated it needs about 450 additional board-and-care slots to meet overarching demand.
Bergmann said the county team is also looking to boost other resources that combine housing with services such as permanent supportive housing.
He said the county expects to eventually build some new board-and-care capacity , but for now, county behavioral health staffers are tapping existing providers. The county expects to use most of the state dollars to boost Medi-Cal reimbursements for willing board-and-care providers. The county also plans to use a small portion of those funds for start-up needs such as furniture, equipment and renovations.
“We can’t just materialize (board-and-care resources) by snapping our fingers,” Bergmann said. “We have got to find providers that are willing to do this work and make sure we are getting them resources.”
Bergmann believes that increasing Medi-Cal payments for board-and-care facilities will level what has long been an uneven reimbursement playing field for behavioral health patients that incentivizes providers to take in other patients who bring with them larger reimbursements.
As Bergmann’s team makes those calls, they are also staffing up to facilitate increased behavioral health assessments and other demands tied to CARE Court.
As of Tuesday, Bergmann said the county had hired about 40 percent of the 55 behavioral health services workers it deemed necessary for CARE Court. Many of those new workers are clinicians who will spend two weeks investigating and preparing reports for the Superior Court after CARE Court petition are filed in court. They can ask for a 30-day extension if needed.
Bergmann said the county plans to engage with the potential CARE Court patients while it conducts those investigations and is hopeful it can persuade at least some patients to access treatment absent a formal CARE Court order.
Superior Court Judge Kimberlee Lagotta, who is leading San Diego’s CARE Court implementation, said the Superior Court’s Collaborative Courts division – which handles existing mental health and drug courts – expects to hear those CARE Court cases downtown on Tuesdays and Wednesdays. She said the court is also investing nearly $3.4 million in state funds into equipment and self-help centers to facilitate remote appearances and filings at courthouses throughout the county.
Lagotta noted that judges will work to make CARE Court a more informal “non-adversarial atmosphere” for participants. The county Public Defender’s Office is preparing to represent CARE Court participants in those hearings and expects to hire 12 staffers to facilitate that work. The Superior Court, however, plans to rely on existing staff.
Lagotta declined to comment on county projections on the number CARE Court petitions, but said she believes the Superior Court is equipped to handle what’s coming its way.
“If we need to expand that process, we can. If we need to reduce that process, we can, based on the numbers,” Lagotta said. “But I can’t speculate at this point what those numbers will be.”
Lagotta was more clear on how she expects the Superior Court judges to handle situations where the county can’t quickly deliver on what’s been prescribed in a CARE Court participants’ care plan, particularly when it involves housing. Judges could issue fines if the county can’t deliver.
“If the resources aren’t there, then it would be very difficult to sanction the provider when they don’t have that option,” Lagotta said. “I think we have to think reasonably about this, and the court certainly intends to work with (county Behavioral Health Services) and understands the limitations on resources, financial limitations in the community and [plans to] move forward with positive efforts that can evolve over time.”
Uncertainty About What’s Next
A safety assessment form in a medical examination room at Sharp Mesa Vista Hospital on Sept. 20, 2022. / Photo by Ariana Drehsler
The ultimate success of CARE Court will rest on the county’s ability to come up with treatment and housing.
It will also require that San Diegans understand the process – and several advocates and providers who work with the county told Voice they have yet to be briefed on the specifics.
Anita Fisher is a mental health consultant who joined Newsom at a March press conference about statewide behavioral health reform. She has shared the story of her own struggles to help her adult son with schizophrenia with the governor and advocated for CARE Court at the state level. Fisher has sat through state CARE Act working group meetings and other related discussions. She’s been waiting for updates on how the program will roll out in San Diego.
“We haven’t heard a thing on the local level,” Fisher said last week.
Cathryn Nacario, who leads the National Alliance on Mental Illness San Diego, a county contractor, said her group and its county-backed Peer Council are eager for details and to give input on how to help the program succeed. She said last week they hadn’t received updates.
“We want to be part of these discussions to really make sure we have an equal voice of the client and the family and caregiver during this process,” Nacario said.
Michelle Routhieaux, president of the San Diego chapter of Depression and Bipolar Support Alliance who helps with the county’s Psychiatric Emergency Response Team training, said she also hasn’t heard any updates.
“We’re not being included on any of it,” said Routhieaux, who is concerned about the CARE Court process and considers its focus solely on psychotic disorders discriminatory since other disorders aren’t covered.
She’s also concerned about the broader array of people who can petition the court for a patient’s care. She fears this may enable family members to abusively threaten to petition the court if they disapprove of the choices a family member with a serious mental illness is making.
“It’s taken us back a lot of years in terms of rights and freedom and even just that semblance of peace or safety,” Routhieaux said.
At least one local health system is also concerned – and frustrated that its leaders don’t have more details on how CARE Court will work.
Gold of Scripps Health said he believes the county and state should build up the behavioral health system before pursuing tacks like CARE Court. He has questions about the new process and how it could impact hospitals.
“We just don’t have enough information to know how it’s actually gonna work,” Gold said. “I know the public defender will be involved, but our concern is there’s just not enough information out there and people will perhaps misuse the tool and bring (patients) into the emergency room thinking it will solve the problem.”
Bergmann said the county is now working to address concerns – and on ramping up information sharing, including on its website. He said CARE Court’s status as a state mandate has minimized the county’s ability to take feedback and apply it.
“This is an extremely prescriptive initiative. This is not a county program. We didn’t invent it,” Bergmann said. “We didn’t invent the nuance of the terms. There is not a great deal of latitude in how counties can operate this.”
Bergmann said the Newsom administration also “inflated expectations” for CARE Court when it first announced in a way that fueled more questions and concerns.
“The reality is that it’s a program that is meant to actually serve a quite small percentage of the overall numbers of people with behavioral health conditions, let alone the overall number of people who are experiencing homelessness or people who may need help with mental health,” Bergmann said. “So the work in sort of level setting has been different than I would say with other initiatives where the messaging from the source of origin has been maybe more consistent with the scale of the actual work.”
Even with those small numbers, the county has a lot of work to do before October.
Voice of San Diego is part of the Mental Health Parity Collaborative, a group of newsrooms that are covering stories on mental health care access and inequities in the U.S. The partners on this project include The Carter Center, The Center for Public Integrity, and newsrooms in select states across the country.
