Santa Monica, Los Angeles County and the State are embroiled in a mental health care crisis and nowhere is this more visible locally than on the city’s streets where individuals experiencing extreme mental illness frequently languish and sometimes perish. 

The shortage in mental health care is also seen in the rising rates of teen depression, anxiety, suicide and overdose as well as in depression and isolation among seniors. City officials are exploring addressing the nationally growing problem on a local level by opening a behavioral health care center.

Where that center will be located, what services it will offer, how many beds it will hold and what population it will serve are all up for discussion.

“I think at this point everything is on the table,” said Maggie Willis, human services administrator. 

The City issued a request for proposals to conduct a feasibility study for building a behavioral health center in Santa Monica, which will close on May 24. Council will select a vendor towards the end of summer who will begin the research and community input process to come up with a vision for the potential center. 

“I think the goal is really for it [the behavioral health center] to be informed by the people who will be using it and so I think really spending time to understand what consumers of these services need and want and will accept will be imperative, because everything has to be voluntary,” said Willis.

The current need for mental health services in Santa Monica and the County is profound. 

According to a study by the RAND Corporation, the state of California requires approximately 50 inpatient mental health beds per 100,000 people. In Santa Monica, a city with approximately 93,000 residents and an estimated daytime population of 250,000, there are zero inpatient beds. 

RAND researchers divided these 50 required beds into roughly 26 acute beds, which are typically used for 72 hour psychiatric holds in emergency situations, and 24 subacute beds, which are typically used for longer-term care for people with more chronic mental health conditions. Generally speaking, both are locked facilities that place limits on patients’ freedoms. 

At a County level, the researchers found that while Los Angeles as a whole does not have an acute bed shortage, it has a shortage of 5.2 subacute beds per 100,000 people. Additionally, it has a shortage of 11.5 residential beds per 100,000 people. Residential beds typically don’t have the same restrictions on freedom as acute and subacute beds, but are rehabilitative care facilities where individuals experiencing mental illness receive housing support and other wraparound services to help them transition back to an independent and stable life.

While Santa Monica does not have any mental health beds (inpatient acute, inpatient subacute or residential,) there are beds available regionally. 

The nearest mental health hospital is UCLA Resnick in Westwood, which has 74 inpatient beds. This hospital is in the process of relocating to Mid-Wilshire, and although the number of inpatient beds is expected to increase by 30 percent, they will be a farther distance from Santa Monica. 

Another local problem with inpatient bed availability is that even though beds are present in the greater region, they are not accessible to everyone. 

“Our settings are not necessarily equipped to deal with populations like people with complex physical health needs or those with prior convictions… and those are things we have a lot of in LA County in particular,” said Nicole Eberhart, RAND Corporation Senior Behavioral Scientist, later adding, “one issue is about 15 percent of the acute facilities won’t take MediCal, so while we found that LA actually doesn’t have a shortfall of acute I want to kind of put some caveats and grains of salt to that because it still doesn’t mean that everyone who has an acute need can get a placement.”

Restrictions on who can access beds is a pertinent problem for Santa Monica. 

For example, when the Santa Monica Police Department issues 72 hour holds for individuals experiencing a mental health crisis, such as a psychotic or suicidal episode, officers most often transport subjects all the way to Harbor-UCLA Medical Center. This is because Harbor-UCLA is the nearest facility equipped to intake people who are uninsured, possibly violent, under the influence or have a criminal record. 

Although many aspects of Santa Monica’s potential behavioral health center are up in the air, one thing staff have said they want for certain is a “no wrong door” approach where extenuating circumstances do not limit someone’s access to care.

“What we want to try to do when we say no wrong door is we don’t care what your diagnosis is, we don’t care what your insurance is, we don’t care if you’re housed or unhoused, we don’t care; come here, we will figure it out,” said Willis. 

While Santa Monica will be striving to increase accessibility to mental health services, it is unclear whether the potential center will make a dent in the regional bed shortage. 

“I think there have been very vocal members of the community who want more inpatient beds, but they are very, very expensive,” said Willis, noting that the city has limited funding for the center and later adding, “do we want to spend it all on something that’s very, very expensive and might have to be small scale and serve a very narrow population? Or do we want to do some things that can still fill a need, but serve a more diverse population?”

One of the largest local advocates for increasing inpatient bed availability is local resident Stacy Dalgleish, who is the former president of the Santa Monica Mid-City Neighbors and the current chair of the Los Angeles County Mental Health Commission. 

Dalgleish led the push to have Providence Saint John’s, a 226-bed Mid-City hospital, include inpatient beds as part of its Phase Two Master Plan. This plan, which was approved by City Council in March, constitutes a massive facilities overhaul that will lead to the creation of ten new structures and several new services. Inpatient beds will not be among them.

PSJ officials have said that they are unwilling to incorporate inpatient beds into their plan and instead see their contribution to the mental health crisis as providing mental health urgent care (treatment for under 24 hours) and outpatient services. According to PSJ estimates, an inpatient facility would cost around $1.4 million per bed to set up and the ongoing operating costs for a 50 bed facility would be around $14 million per year, escalating annually.

As a compromise, PSJ will be providing a $10 million grant for the city to fund behavioral health initiatives as part of a greater community benefits agreement, which is estimated to provide $100 million in investments in the city over the next 30 years. City staff have earmarked the $10 million grant for capital expenditures to build the potential behavioral health facility. 

One reason Dalgleish is a strong advocate for inpatient beds is because she believes that providing an inpatient intervention of high quality care when someone experiences a mental health crisis goes a long way to prevent mental illness from worsening. Dalgleish also has a strong focus on ensuring inpatient care is followed with robust outpatient services. 

“The majority of people who end up with a first psychotic episode…they don’t end up being treated to cure. It is possible for someone to have a first psychotic episode and never have another psychotic episode, but that means that when they have the first psychotic episode, they are not just released to the wind after 72 hours or 14 days with maybe a card in their hand of somebody to call,” said Dalgleish. 

Dalgleish said that follow-up care requires working closely with that individual’s network of friends and family to ensure that they take their medications, are in a supportive environment and continue regularly engaging with mental health professionals.

“The sooner that you stabilize the brain, the better for long-term consequences for the wellness of the individual and that means not letting somebody end up having another psychotic episode, because every time you have one your brain gets disturbed again,” said Dalgleish. 

Many times when patients are released from a temporary hold they are discharged to their same unstable environment or even the streets. This can lead to costly cycles of repeat 911 calling and short-term holds where the patient’s mental illness progressively worsens. 

For Santa Monica specifically, Eberhart said she would recommend that any potential behavioral health center focus on providing subacute beds and, in particular, residential beds.

“LA County has really serious shortages at the community residential and the subacute levels of care and so if you don’t deal with those levels, it’s hard to deal with anything above it,” said Eberhart.

These bed shortages create bottlenecks in the County’s mental health care system. 

According to the RAND study, at least one in ten patients in an acute bed would be better suited to a subacute bed, but cannot move due to lack of capacity. In addition, the subacute administrators that researchers spoke to said they would move around one-third of their patients to community residential beds if there was availability. 

The consequence of such bottlenecks is that many mentally ill individuals in LA County are not getting the care best suited to their needs and are at times unnecessarily living in locked door facilities where their rights are impinged upon.

When it comes to building more residential community facilities, Eberhart also embraces a no closed doors approach and recommends opening such facilities to hard to place populations like the justice involved. 

“Nobody wants a facility that is not locked that has people with a criminal justice history, because of nimbyism issues, but honestly that is what is needed,” said Eberhart. “Like those are the folks that are hard to place and if you cannot place them in a setting that’s going to be supportive, they may end up on the street, and is that really better?”

While not commenting on a specific type of bed facility, Willis said the city is interested in a behavioral health facility that takes a holistic approach to patient care, by potentially also providing services like job training, counseling with family members, and assistance finding housing. 

At the end of the day Willis maintained that the shape of any potential Santa Monica facility will be based on community and stakeholder input. 

“This is a big thing. The community is going to have a lot of feelings about it,” said Willis. “We need to hear that, we need to be able to make sure we can work with them to decide important things about where it is, and what does it look like, and how does it function, and who does it serve.”