Breaking the Cycle 

For the third time in 15 months, the medical director of the Mental Health Branch of the Humboldt County Department of Health and Human Services has resigned. The latest resignation, by Dr. Raja Dutta, comes just two months after the local medical society called for a grand jury investigation into the department's ongoing staffing crisis, saying not enough was being done and warning, ominously, that the department's "culture is not changing."

It was just about 11 months ago that mental health's troubles first bubbled into public view with the joint resignation of the department's two highest ranking doctors, who happened to be the only psychiatrists staffing the county mental hospital. The departure of doctors Jasen Christensen and Jonathan Greenberg — who took the unprecedented step of sending a seven-page report to the Humboldt County Board of Supervisors, blowing the whistle on the departmental mess — caused the county to turn to a third-party psychiatric staffing company in March, offering it $3.5 million to do what the county could not: recruit and retain psychiatrists.

Almost a year later, it's not easy to find many signs of progress. Traditions Behavioral Health — the company tapped by the county — has averted an outright collapse of the mental health branch, an outcome that seemed possible after Christensen and Greenberg's resignations threatened to leave one psychiatrist staffing the department where there used to be 10. But the company has largely done so through the use of traveling doctors and has yet to field the type of permanent, local staff it pledged to deliver.

The facts on the ground remain dire. In the county's outpatient program — which provides psychiatric services and prescriptions to about 1,000 people — some patients are waiting months for an appointment. Meanwhile, in the county's acute care facilities — Sempervirens mental hospital and the Crisis Stabilization Unit — staff continue to express concerns about dangerous working conditions and inadequate patient care. And doctors continue to want out.

But there is a glimmer of hope emerging on the horizon, as Traditions Behavioral Health feels it has zeroed in on part of the reason the county's struggled to find stability at Sempervirens — which appears to be the epicenter of the mental health branch's struggles — and has gotten the OK to revamp the hospital's staffing structure. Gary Hayes, the company's founder and president, told the Journal he is optimistic the county's mental health branch could be fully staffed by July. If so, it would constitute the first time in recent memory that the department is not in need of a psychiatrist.

In a report sent to the board of supervisors in March, Christensen and Greenberg laid out what they saw as the department's endemic and entrenched problems. There was the staffing shortage, which they claimed was the product of the county's lower-than-market salaries and lackluster recruiting efforts. This caused the county's psychiatrists to be overworked and, often, to fill shifts outside of their preferred placements. It also necessitated reliance on "locum tenens," traveling physicians who fill in for short stints. The chronic staffing crisis translated to poor patient care, the doctors argued, with unmanageable caseloads, gaps in coverage and an overwhelmed medical staff. This left doctors frustrated, feeling overworked and underpaid, fearing for both their safety and their exposure to liability.

In the face of these conditions, some doctors left, which exacerbated the situation for those who remained. This vicious cycle continued, Christensen and Greenberg charged, until they were nearly the only ones left with little, if any, prospect of reinforcements arriving. (The pair claimed the department had managed just five candidate interviews over a five-year period despite continuously vacant positions.)

But Christensen and Greenberg's report hints there are problems within the department that run deeper than staffing levels. At one point, they referenced "day to day frustrations with administrative decisions and the continued effort to deflect responsibility." At another, they noted that "the medical staff shortage ... is only the tip of the iceberg, as it is the result of many underlying problems with the basic administrative and management decisions as they affect patient care, hospital and clinical policies and staff relations."

Contacted by the Journal recently, Christensen — now working for Open Door Community Health Centers — said he was "unwilling to comment." Attempts to reach Greenberg were unsuccessful.

In a pair of letters to the board, the Humboldt-Del Norte County Medical Society also made clear that it believes the mental health branch's issues run deeper than the countywide challenge of recruiting increasingly in-demand doctors to come work in an isolated rural area. Back in April, society President Jon Nelson wrote, "There is an ingrained and dysfunctional culture that needs fundamental change," noting that Greenberg and Christensen's letter came after the pair had worked to resolve the issues internally with the administration and that the letter was "an exceptional step for these physicians to take."

In a follow-up letter in November, Nelson's frustration is palpable: "We are sending another letter because the lack of response from the Department of Mental Health, and the director of DHHS to the crisis is discouraging. We have seen little in the way of definable progress." The letter goes on to state that the medical society has "received reports that it is a pervasive culture of bureaucratic indifference to the input of employees and the community that is toxic to relationships within the Department of Mental Health, and between the community and the department." Medical staff in the department, the letter says, "has insufficient authority to direct patient centered care." The letter goes on to call for a grand jury investigation and a public hearing before the board of supervisors.

Mental health staff interviewed by the Journal, who spoke on the condition of anonymity, fearing retribution for speaking publicly, described an environment in which some administrators are controlling and attempt to micromanage staff, including psychiatrists. "They want to wag the dog," one employee said. Several employees described situations in which administrators had overruled a psychiatrist's decision over whether to admit or release a patient.

DHHS administrators have repeatedly pledged publicly to improve communications with staff.

Those who work inside the department say the inability to retain staff has created a vicious cycle of dysfunction that impacts every level of patient care.

In outpatient services, there are two regular doctors where there used to be six. (Two positions remain vacant and two are filled via tele-psychiatry.) A staff member we spoke to — who is in charge of evaluating patients and scheduling them to see a doctor — said staff are booking patients into April. Patients who may need changes to their medications are waiting months to speak to a psychiatrist and the psychiatrist they do see is probably not the one they first met, meaning there is no continuity of patient care. Patients sometimes run out of their medications before a physician can sign off on a refill.

County mental health services can be viewed as a delicate house of cards: Pull one card and the whole thing is likely to come down. Sempervirens and the Crisis Stabilization Unit are all about acute care, de-escalating and stabilizing people suffering immediate psychiatric emergencies, which are usually exacerbated existing conditions. Sempervirens is not designed for long-term hospitalizations; patients are stabilized and released to outpatient care or transferred to a state or private hospital for ongoing treatment. So, problems in the outpatient division of mental health — like patients being unable to have ongoing, secure medication supplies that are monitored by a physician — lead more people to crisis states that necessitate acute care. Inadequate acute care releases people back into the community in border-line crisis states.

According to staff, current backlogs in the outpatient unit mean patients are ending up in the crisis stabilization unit, or CSU, with mental health crises that possibly could have been avoided had they received proper preventative care.

"People come in that have [post traumatic stress disorder], they're schizoaffective, have borderline personality disorder and are unmedicated," said one staff member. "I have to tell them they can't see a doctor until April."

In an email interview with the Journal, Mental Health Branch Director Asha George said wait times for outpatient appointments with psychiatrists range from two weeks to two months, which she said is "too long." But, she added, "This has not been exclusively due to the lack of availability of physicians but also has to do with patients not showing up for appointments (which is not unusual for chronic and complex patients in any system of care). Staff are constantly triaging who needs to be seen soonest."

Some outpatient workers who feel their patients need a doctor immediately send them to the crisis stabilization unit, which staff says is "completely slammed." CSU operates on a medical rather than therapeutic model, meaning those who arrive while in a manic or schizoaffective state are stabilized with a "cocktail" of medications so they won't be a danger to nurses or other patients. This practice, called "chemical restraint" is frowned upon by the American Psychiatric Nurses Association, but those who work in the unit say it happens with regularity, the product of an overworked staff trying to keep the facility from devolving into total chaos.

"When they refuse meds, [staff tell them] they won't be able to get out of their handcuffs or will have to go to Sempervirens," one staff member said. "Everyone gets medicated and goes to sleep."

This means some patients leave the facility without having a true psychiatric evaluation because they are too drugged for assessment, said a staff member. A different staffer recalled being asked to make a discharge plan for patients and not being able to talk to them all day, despite going by their beds multiple times to wake them up.

Employees inside Sempervirens have repeatedly asked for an increased security presence because of what they consider unsafe working conditions. Staff have sustained injuries on the job, including broken ribs, according to sources. On some shifts, an entire female staff can be left in charge of large, potentially volatile male patients.

"Nurses," one staffer said, "can be cornered anywhere, including in a patient's room."

Adding to the volatility, staff said it has become more common for law enforcement officers to bring in patients who are still under the influence of controlled substances. Multiple people who work at Sempervirens said this change came after the death of Father Eric Freed, the St. Bernard's Parish pastor who was beaten to death on New Year's Day of 2013. Sempervirens, one staffer told the Journal, isn't built to provide detox services and it's nearly impossible to conduct a mental health evaluation of someone who's under the influence of methamphetamine. People under the influence, he said, get little benefit from being at the facility, yet can pose a danger to staff and other patients.

When asked about his department's policy dictating when people are taken to Sempervirens for involuntary commitments, Eureka Police Chief Andy Mills said, "Sempervirens will not take people under the influence of meth or other drugs."

Sitting in the Journal office one recent afternoon, Traditions Behavioral Health Founder and President Gary Hayes came across as chipper — no small feat, considering he'd left his Napa home at about 6 a.m. that day to make the drive north. He was clad in a pristine gray suit, his brown hair neatly parted to the right.

Hayes recalled a day, some 15 years ago, when his company was just starting up and his phone rang out of the blue. "I got a call asking if I was interested in bringing six psychiatrists up to Humboldt," he said, smiling slightly. Hayes says he signed on and delivered the needed doctors to help save a department in crisis. It was 2000. A year and a half later, he got another call, this one from the county asking to buy him out of the contracts and take over employment of the aforementioned psychiatrists. Hayes agreed, and he and Humboldt parted ways, the only time Traditions has seen its contracts bought out, according to Hayes.

Traditions employs about 150 doctors who work at hospitals and facilities throughout the state, Hayes said. The doctors are employees of the company, which contracts with counties, hospitals and other institutions to provide staff. Generally, Hayes said, his clients are in a state of crisis when he gets a call. "In order to bring in a company like Traditions Behavioral Health, something bad is happening," he said, adding that most of his clients ultimately deem the relationship beneficial and have no interested in going back to staffing their own doctors.

Back in 2001, Hayes said, Traditions was new, having opened five years earlier, and didn't have much of a reputation. That first staffing of Humboldt, he said, was a feather in the company's hat. Why? "Because if you can bring six psychiatrists to Humboldt, you can do anything," he said. Asked why it's so hard to recruit psychiatrists to come work in Humboldt, Hayes squirmed slightly, perhaps the only point in the nearly hour-long interview where he seemed uncomfortable. "I tell candidates that Humboldt is a five-hour drive from Macy's," he said. His point is clear: Humboldt is rural and isolated, not a place that universally appeals to folks making north of a quarter of a million dollars a year with a world of options at their fingertips.

After signing on to again try to save Humboldt's mental health department from collapse, Hayes said he and his staff analyzed the situation. He said it was "alarming" that doctors here had gone public by sending their concerns to the board of supervisors, and that he feared it would constitute a self-fulfilling prophecy. You call something a crisis enough, he said, and it not only becomes one but stays one.

After signing a $3.5 million contract with the county, Hayes said one of the first calls he made was to Paula Edwalds. Hayes had recruited Edwalds to come to work for him in Humboldt back in 2001, first as a traveling doc and then permanently. She'd been here 14 years when she resigned in February, following Christensen and Greenberg to the door. In her letter of resignation, Edwalds said she'd made her home in Humboldt and was reluctant to leave, but was frustrated at the state of the department, poor working conditions, her daunting caseload and the chronic understaffing, which often saw her pulled from her child outpatient post to cover shifts at Sempervirens and the CSU. Hayes said he asked Edwalds to come back to work for Traditions in Humboldt and she quickly agreed. Pressed, he conceded he also offered her a substantial raise from what she'd been making from the county and assured her she would spend all her days doing child outpatient work, and wouldn't get pulled to cover shifts at the hospital.

To Hayes, this is emblematic of some of Humboldt's problems recruiting and retaining doctors. First and foremost, he said, the county's salaries are below market rate. Second, he said, there's a lack of understanding of who doctors are and what makes them tick. "You can sort of be forgiven for thinking a psychiatrist is a psychiatrist is a psychiatrist," he said. "But you really need to understand they have specialties and interests."

Through the use of his network of traveling physicians, Hayes stabilized staffing in the department and ultimately hired two doctors to take over the day-to-day coverage of the Sempervirens shifts. Those two doctors now want out — Dutta, Hayes said, is leaving for personal reasons and the other is switching to outpatient work. Reflecting on the situation, Hayes said he and his staff came to an out-of-the-box solution. "We started thinking, maybe the problem is mathematical," he said, explaining that having two doctors working Monday through Friday at Sempervirens leaves the department vulnerable. "When you have four feet on a stool, it's stable. When you have two prongs on the stool, it is not."

Hayes is now switching to what he calls a "shift" staffing model at Sempervirens. Currently and historically, the county has depended on two doctors to each work parallel 8 a.m. to 5 p.m. shifts on weekdays, providing 16 hours a day of psychiatric service in the hospital. Beginning in February, one doctor will provide the same 16 hours of service by working a 7 a.m. to 11 p.m. shift. This, Hayes said, will allow the county to employ four doctors at the facility, each of whom will work no more than 10 days a month, logging no more than 160 hours — the same as a 9-to-5er would. The cost to the county will be about the same, he said.

The advantage of this model, Hayes said, is it will be far more attractive to prospective doctors, as they will have some 20-plus days off a month, allowing them more down time and the opportunity to travel out of the area. It will decrease burnout, he said, and also allow more flexibility, so if one doctor leaves it won't send Sempervirens' staffing into crisis, starting the trickle-down effect that impacts other mental health units. Hayes said the staffing model also affords a better continuum of care for patients, as the same doctor will be in the facility throughout the day to monitor the effects of new medications and treatments.

Additionally, and importantly, Hayes said it will double the daily window in which a doctor is in the facility, allowing for after-hours doctor-to-doctor calls from local hospitals. It will also greatly decrease the amount of time in which no doctor is present at the facility to screen involuntary commitments from local law enforcement officers. Hayes conceded this has been a problem, with officers sometimes bringing people to the hospital who don't belong there, whether it is because they are under the influence or don't meet admissions criteria.

In her email interview with the Journal, George, the mental health director, sounded optimistic about the new staffing plan, echoing some of the same benefits that Hayes listed, including that there will now be a physician on site to oversee ongoing admissions and discharges until 11 p.m.

Others don't seem so sure about the proposal. Two people who regularly work in Sempervirens told the Journal the shift model is concerning. They pointed to studies that show physician error rates increase after 12 hours on the job, and also questioned what would happen if there were two incidents that demanded immediate physician attention at the same time.

Asked to assess the potential positives and negatives of the new system, George's email only listed the aforementioned hoped-for benefits.

When it comes to other concerns about the way the county mental health department is run, Hayes didn't seem overly concerned. He said Traditions simply doesn't stick around in situations that aren't fixable. "If we find administration impossible, we don't stay. It's that simple," he said. But he conceded that, from a doctor's perspective, there have been some issues.

"Administrators can be preoccupied with details that don't seem important on the floor — there can be a disconnect there," he said. And, Hayes said, part of his job is addressing those things, acting as a buffer between administrators and his physicians. For example, Hayes said he's worked with local administrators to revamp the admissions criteria to Sempervirens, making sure the patients admitted to the facility belong there. And, he said, he tells his doctors very clearly: "Don't fuck with administration. If you have a problem, turn to us and say, 'Make this go away.'"

George said Traditions has worked to make sure folks being admitted to Sempervirens are suffering from "acute psychiatric conditions that cannot be managed or resolved through crisis stabilization services," allowing for better utilization of the CSU. The director described the county's relationship with Traditions as a "work in progress," but struck an optimistic tone. "Dealing with complex human systems is never easy, but Dr. Hayes and his team have been receptive to our questions and concerns," she wrote. "Communication is good, and obviously staffing levels are much better. Patient care is improving, and that's what matters most."

For his part, Hayes said the key for Humboldt County's mental health crisis is stabilization, breaking the cycle it's been mired in for years. The first step is adequate, consistent staffing. Then, some of the cultural problems that have publicly spilled over can start to be addressed. To that end, Hayes said he's also asking the county to hand over the staffing of two outpatient psychiatrists — positions the county retained staffing control over when contracting with Traditions back in March but has been unable to fill — to him. He said he's already got psychiatrists willing to come on board, he just needs the OK to hire them. George, meanwhile, said the county is considering contracting out one of those vacant positions to Traditions, but negotiations are ongoing.

In many ways, the Mental Health branch is like patients entering Sempervirens: It's in desperate need of acute care so it can be stabilized and a long-term plan can be developed. Traditions' chief task has been that initial stabilization but, 10 months after its contract was inked, the crisis remains.