The California Department of Mental Health has notified Fresno County that its only psychiatric crisis center for children does not meet state guidelines -- and now the county is fighting to keep it open.
While no decision has been made, county officials say that closing the 24-hour center would force children to wait for hours for care in ill-equipped hospital emergency rooms.
Those emergency rooms already are overwhelmed with hundreds of mentally ill adults who have nowhere else to go, advocates say, because the county closed its adult crisis center in 2009 amid a funding shortfall.
The result: Fewer children would get the intervention they need, leading to more hospitalizations. That would be costly for the taxpayer-funded mental-health service, and also harmful to the children, advocates say.
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"We've turned our back on the adults in Fresno, so are we going to turn our back on children also?" asked Lauri Randle, a Clovis parent who had a daughter at the children's crisis center in 2007.
County officials already have sent the state a report and contacted state officials by telephone in their bid to keep the center open, but at least one of the state's concerns appears to be insurmountable: the center is not adjacent to a psychiatric hospital for children and adolescents, a long-standing guideline for such centers.
Until now, the state has not made that an issue. But in an e-mail message in December, state officials brought it up, along with a second concern: the center needs more staff.
While Department of Mental Health spokeswoman Jennifer Turner has characterized the concerns as just one part of a "routine process of receiving updated information from each county," county officials are worried.
"Clearly, I do not know which way they're going to go with this," said Donna Taylor, director of behavioral health for Fresno County.
A history of helping
Since September 2002, the crisis center has operated in the former Valley Children's Hospital in central Fresno.
Taylor said that to her knowledge, it's the only center of its kind in the state. Other counties respond to children in crises by sending mental-health workers to homes, she said.
The advantage of the crisis center, she said, is that it provides an alternative, short-term place for children instead of hospitalization. Of the 456 children in the center from August to October 2010, only 56 were hospitalized, Taylor said.
More than 100 children a month are brought to the crisis center -- most by law enforcement. The children can be involuntarily retained for up to 72 hours for their well-being and the public's safety, and to receive help.
Children who cannot be helped within 23 hours at the center are sent to psychiatric hospitals.
The time children stay at the center varies. Sometimes they are there for an hour or two. Some spend the night. The average length of stay is eight hours.
The center has a day room and some seclusion rooms for children who need to be isolated for care and safety. It can hold up to 12 children and adolescents at one time. A psychiatrist is available when needed, and mental-health clinicians and licensed vocational nurses are there around the clock.
The budget for the children's center is $2 million. Of that amount, $1.5 million is from realignment funds, money the county receives from sales taxes and vehicle license fees each year to pay for mental-health services. Another $500,000 is a mixture of state and federal funds and some money from private insurance.
The county has received less in realignment funds in the economic slump and has cut mental-health services, including closing the adult psychiatric crisis unit in July 2009. That center cost $5.9 million a year to operate.
But under pressure from hospital officials, the Board of Supervisors last month ordered county staff to find a private contractor to operate an adult center, saying the county needs it.
Meanwhile, the mentally ill have fewer places to go for help.
The ER crunch
Hospital emergency departments have been flooded with mental-health patients in the year and a half since the county closed the adult psychiatric crisis care center.
With the center's closure, emergency departments became the first and only stop for suicidal and psychotic patients picked up by law enforcement.
Mental-health caseloads skyrocketed. At Community Regional Medical Center, for example, more than 500 patients are seen a month, compared with fewer than 200 a month seen in 2008.
Hospital officials argue emergency departments are not equipped or prepared to handle mental-health patients. Only Community hospital in downtown Fresno has a separate, dedicated area in its emergency room for psychiatric care. At other hospitals, mental-health patients wait on gurneys in ER rooms and hallways with the general patient population.
Hospitals would be less able to accommodate children, said Lynne Ashbeck, regional vice president of the Hospital Council of Northern & Central California.
"I don't anticipate hospitals would have the ability to have a separate area in the ER to take care of pediatric mental-health patients," Ashbeck said.
And even ERs inside hospitals built specifically for children are not the best place for a child experiencing a mental-health crisis, said Tony Yamamoto, director of social work at Children's Hospital Central California.
The staff in emergency departments are trained in physical emergency care -- setting broken bones and stopping asthma attacks, for example, he said.
Too often, children having psychotic episodes can sit for hours in emergency departments while doctors try to find an appropriate care setting for them, Yamamoto, said. "I've had a kid in our ED now up to 48 hours," he said Thursday.
Children's Hospital in Madera County sees about four to six children a month experiencing a mental-health crisis, Yamamoto said. The hospital has no mental-health unit; they're seen in the emergency department. Typically, two or three are from Fresno County, he said. He suspects the number from Fresno County would double if the children's crisis center closed.
Finding a way
While money is tight, Taylor said she's willing to make adjustments in her budget to add staff at the children's center to keep it open.
To meet state staffing guidelines, Fresno County would need to add two mental-health clinicians and one licensed vocational nurse, Taylor said.
The county could absorb $300,000 for the additional staff, which Taylor said should address the concern as long as the state also approves the new staff scheduling arrangement that would be required.
The state's other concern is more problematic. Taylor said she can't comply with the requirement that a psychiatric hospital be adjacent to the crisis center.
The closest hospital for children and adolescents is in Bakersfield. Fresno County frequently sends youths as far away as Los Angeles for hospital care.
Taylor said this year was the first time she's seen the adjacent-hospital requirement on the state form the county submits to the state for the crisis center designation.
She hopes the state will reconsider the hospital requirement in Fresno County's case. "I'm not sure what position or how hard a position they're going to take with that," she said.
Turner at the Department of Mental Health said an adjacent hospital is not a "rule, instead it is a guidance the department has followed since the mid-1990s." The guideline applies to adult psychiatric crisis centers as well as children's units.
The state has not rescinded a crisis center designation for a children's or an adult center for not meeting the hospital guideline, Turner said.
But Fresno County's children's center is the only free-standing designated children's crisis center in the state. Others are within or next to 24-hour licensed hospitals, Turner said.
Taylor said she prepared a report about the county's center for the state's consideration. She submitted it on Jan 12 to the Department of Mental Health, but she has yet to receive a response.
In a telephone call to state officials, Taylor said she "stressed to them how important I think this is to our community."
The state is looking at policies and requirements and how they "may be modified to better meet the needs of counties while still assuring health and safety," Turner said. It will take into consideration concerns and suggestions from counties, she said.
Meanwhile, Taylor waits.
She asked the state for one favor, she said: "If you're going to take this designation away, give the county some time to do some transitional planning."