Faced with a growing mental health service crisis, the Humboldt County Board of Supervisors quickly and concisely agreed to a year-long, $3.5 million contract to staff the county's mental hospital and other services this week.
It was a relatively fast response to a situation that boiled over only a month ago — though it appears to have been simmering for years. Facing long hours and dangerous working conditions, employees of the county's mental health division have been resigning, exacerbating the troubling conditions for remaining employees and for the patients and their families who rely on the county. Everyone agrees: Mental health services are crucial for public safety and the wellbeing of those who directly rely on them.
So, on March 17, supervisors voted unanimously to bypass the county's ineffective recruitment and staffing of the division and hand the task to a third party. At the meeting, hopes were high that this would turn the division around, right at a point when mental health staff expressed fear "that the people of Humboldt County stand to lose their invaluable mental health services."
On Feb. 6, interim Medical Director Jonathan Greenberg and Medical Staff President Jasen Christensen wrote a seven-page letter to the board of supervisors, detailing a crisis five years in the making.
"The most critical and proximate cause of the crisis is a significant and growing medical staff shortage, which is leading to inadequate patient care," read the letter, which each doctor signed. "The medical staff shortage, however, 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 clinic policies, and staff relations."
Those problems included poor recruitment and retention strategies; poor staff morale; poor administrative communication; unsafe working conditions at Sempervirens, the county's psychiatric hospital; significant workload increases, including weekends, with no overtime pay; and a cumbersome electronic medical records system.
The snowballing staffing shortages, culminating in the resignation of child psychiatrist Paula Edwalds, led to four-month waiting lists for patients, patient grievances, and liability concerns, including, the letter notes, a January suicide.
Edwalds, whose departure apparently leaves the juvenile hall without a designated psychiatrist, submitted a letter of resignation the same day as Greenberg and Christensen (find links to both letters in this story), writing, "My perception of the situation is that administration has not felt the same sense of urgency to find new physicians that the current staff has felt."
In their letters, the doctors note that five psychiatrists resigned in two years. In the previous five years, only five doctors were interviewed — four of them turned down positions. A child psychiatrist turned down a position because he or she was expected to also see adult patients and provide weekend inpatient coverage.
Sempervirens is Humboldt County's only psychiatric care hospital — the only "locked hospital-based treatment" of its kind within 300 miles, according to the county website. Despite that, it's a small facility — with 16 beds and a typical population of around 11 patients. It's not intended for long-term care, like California's state hospitals, but merely as a temporary place for people who are dangers to themselves or others, or who have a serious psychiatric disability.
The county also offers psychiatric emergency services — day-long intervention treatments that are intended to prevent hospitalization — and provides a variety of adult and child outpatient services. At the March 17 meeting, Health and Human Services Director Phil Crandall said the county is experiencing a surge in people eligible for Medi-Cal. About 2,300 adults and 600 youths receive care from county mental health services, and about 1,100 of them require medication at any given time.
The population of eligible patients might be growing, but some people fear that population is changing as well. Prison realignment and a recent decriminalization ballot measure have released low-level offenders from state prison. The ballot measure also put strains onto alcohol and drug recovery services in the area, which could tax police departments and mental health services.
The February letters, along with statements from officials and community members, indicate that working for Sempervirens — while always risky — is increasingly dangerous. Several speakers during the March meeting, after praising the county's staffing contract, called for an audit at the hospital to adjust policies and procedures to make employees safer.
Safety was one of a variety of factors that Greenberg and Christensen said led both to the flight and the difficulty in recruiting psychiatrists. Humboldt's facility is rural and isolated, has an impractical record-keeping system, lacks a medical school affiliation and is out of date, they said.
And, despite Greenberg and Christensen being among the highest paid county employees (in 2012, the most recent year records are available, they earned $312,000 and $282,000 in salary and benefits, respectively), they said Humboldt County isn't competitive in its salary offerings.
Crandall conceded the county's human resources team has been unable to attract candidates, citing increased competition in the recruitment of psychiatrists by the Veteran's Administration and state prisons as one reason.
Recently, the county's been turning to locum tenens psychiatrists — essentially short-term, visiting doctors — as an expensive, and by all accounts ineffective solution.
Enter Traditions Behavioral Health. When the county crisis bubbled to the public surface, Crandall drew up a contract with the Napa-based mental health staffing agency. A week after the potential agreement was announced, the county approved a $3.5 million contract with the company to add 5.6 full-time psychiatrists to the mental health division. Traditions will recruit, hire and place the doctors, bringing the county's staffing to approximately 6.4 full-time doctors. This, Crandall said, will reduce safety issues at Sempervirens.
At the March 17 meeting, several supervisors expressed brief concerns about losing control of doctor recruitment, and 2nd District Supervisor Estelle Fennell asked Traditions President Gary Hayes why the company will be able to recruit psychiatrists better than the county's human resources department.
Those doctors will be Traditions employees, Hayes explained, with salaries and benefits paid by the company. That's appealing to some doctors, though he also indicated that human resources should continue to seek county-employed doctors, nurses and physicians' assistants.
Crandall said that if Traditions uses the $3.5 million the contract allows, it will cost only about $300,000 more than what DHHS is currently paying to have locum doctors and telemedicine psychiatry fill in the gaps.
Hayes said his company focuses on hiring doctors who want to settle in the area, making for a greater continuity of care in the communities where they end up. Because of that, they seek doctors with families, which might make immediate results difficult as potential recruits' kids will still be in school as the hiring process begins in April.
Still, Hayes was confident that Humboldt County's mental health branch will be fully staffed within a year. At the end of the contract, the county will have the option to continue hiring Traditions to staff mental health (at a 15 percent fee), to buy out the contracts for a $50,000 per head finder's fee, or to hire its own doctors.
A long-term solution will no doubt depend on how quickly and efficiently Traditions works to recover Humboldt's Mental Health Branch. Hayes was confident, saying that only one county had ever chosen to buy out his employees' contracts in his company's nearly 20-year history. That was Humboldt County, in the early 2000s.
In a surreal moment during the March 17 meeting, Hayes pointed to a 2001 hire during his company's previous stint staffing Humboldt's mental health division that exemplified his company's ability to find long-term employees. Her name was Paula Edwalds, and she worked for the county for 13 years.