When residents witness a mental health crisis, be it suicide threats, a psychotic episode, or erratic violence, the common response is to call 911. But what happens between that call and the subject’s eventual release is a mystery to many and, unfortunately, many times it leads the patient back to the streets or to the situation from which they came.
In Santa Monica and throughout the state of California, acute psychiatric crises are generally handled with a 72-hour wait. Under the Lanterman-Petris-Short (LPS) Act, a detainer is triggered when individuals meet one of three criteria: they are a danger to others, a danger to themselves, or are severely disabled (unable to meet the basic needs of food, clothing or shelter).
This hold, commonly referred to as ‘5150’ after the appropriate section of the California Welfare and Institutions Code, gives psychiatric facilities the right to detain a patient for a 72-hour observation and treatment period. During this time, patients may not leave the hospital until the hold expires or the treating physician determines that the patient no longer requires involuntary detention.
Staff from the Santa Monica Police Department and the Santa Monica Fire Department are constantly responding to behavioral crisis calls. These include people experiencing suicidal thoughts or actions; drug-induced mental episodes; violence towards themselves or others; bipolar, depressive or schizophrenic episodes, acute stress after a traumatic incident; or a mental disability resulting in the inability to meet their own basic needs.
SMPD and SMFD often work together on these calls, but only police officers have the authority to issue a 5150 hold and involuntarily transport subjects to the hospital. If a serious crime has been committed, officers often search the subject first and then arrange transportation to a facility. In cases where there is also a physical medical problem present or a subject voluntarily agrees to psychiatric treatment, SMFD may make the transfer.
In 2021, SMFD recorded 963 patients who were assessed and treated for behavioral health issues and SMPD recorded 398 police calls as 5,150 stops. (Police officers determine whether an incident is labeled a 72-hour hold based on LPS criteria; however, it is up to medical staff to determine how long a patient is held.) SMPD Public Information Officer and Lt. Rudy Flores said most but not all psychiatric calls involve a homeless person.
SMFD and SMPD transport subjects to different medical facilities based on a variety of factors including subjects’ physical health, insurance status, parole status, presence of violent behavior, and level of sobriety.
Harbor-UCLA Medical Center in Torrance, which can be a 90-minute drive in traffic, is the primary destination for local 5150 arrests, not one of the Santa Monica hospitals.
“Typically, if they are paroled, under the influence, and have 5150 capacity, then yes, they are transported to Harbor General, which is in Torrance,” Flores said.
According to Flores, Harbor-UCLA has agreements with law enforcement agencies to accept patients in involuntary detention and is equipped with the facilities and confinement resources necessary for the majority of people placed in detention by SMPD officers. If a subject is not under the influence, violent, on probation, parole, or also experiencing a physical health issue, SMPD can transport them to the much closer 16-bed Exodus Recovery Facility in Culver City or the Exodus Recovery Facility in Boyle Heights.
If patients are not eligible to transfer to Exodus and have insurance, they are often taken to local emergency rooms, such as Providence Saint John’s Health Center or UCLA-Santa Monica Medical Center. These hospitals do not have inpatient beds for 72-hour holds, but can provide up to 24 hours of mental health care and referrals to appropriate inpatient facilities. Currently, 20 percent of Providence Saint John’s mental health patients are homeless.
The largest nearby hospital capable of managing a hold of 5,150 is the 72-bed UCLA Resnick Neuropsychiatric Hospital in Westwood. There are plans to close UCLA Resnick in the near future and replace it with a new neuropsychiatric hospital campus in the Mid-Wilshire area.
Typically, about half of Resnick’s patients are admitted on a 72-hour wait criteria. Of the patients admitted, about half come alone or accompanied by a family member/friend and the other half are transported by a 911 responder. According to a statement from UCLA Health, “repeat admissions of homeless people in a 72-hour They’re not unusual.”
Once the 72-hour hold expires, homeless people, along with other psychiatric patients, are usually released. Once discharged, many homeless patients return to the streets and there is no legal requirement for them to be connected or accept further treatment or services.
This can lead to cycles of 911 calls by homeless people experiencing mental illness, where they are frequently in and out of psychiatric facilities. The emergency services that transport psychiatric patients and the hospital doctors who treat them are responsible for dealing with emergencies. Their job is to address the urgent mental health issue and then help ensure that emergency vehicles and inpatient beds are available to handle the next crisis.
Housed persons are also on 72-hour hold cycles as they may have difficulty engaging or accessing effective outpatient care after discharge.
This problem exists throughout the state. A 2020 state audit of the implementation of the LPS Act found that from fiscal years 2015-16 through 2017-18, nearly 7,400 people in Los Angeles County experienced five or more short-term involuntary holds, yet only the 9 percent of these individuals were enrolled in the most intensive and comprehensive community services in fiscal year 2018-19.
In Santa Monica, emergency response departments and hospital workers are aware of this problem and are trying new solutions.
In 2016, Providence Saint John’s launched its Homeless Care Coordination Program, which places two community health workers in the emergency department to help connect homeless patients with case managers at local providers. of homeless services and finding temporary or permanent housing after they are discharged.
SMPD has a Homeless Liaison Program that works to connect homeless subjects of 911 calls to services as an alternative to incarceration. This team includes two physicians from the Los Angeles County Department of Mental Health, who have specific expertise in psychiatric crises and can connect subjects to the County’s network of mental health facilities and services.
SMFD also has a specialized unit to better handle calls related to vulnerable or homeless populations called the Community Response Unit. This pilot program launched in September 2021 and features two fire EMTs who have received extensive training on how to respond to psychiatric crises and the homeless resources available in the city.
Standard SMFD engines are required to provide transportation to the ER as quickly as possible so they can be back in service to answer more calls. The CRU has the flexibility to stay on scene for longer periods of time, better understand the issues that led to the 911 call, and build trust with the subject. CRU members may refer subjects to homeless service providers and are the only SMFD staff legally authorized to transport individuals to a psychiatric urgent care facility rather than an emergency room.
From September 13 to December 30, 2021, the CRU responded to 193 calls and interacted with 129 homeless people. During this time, 92 service referrals were made and five people were transported to the Exodus Recovery Psychiatric Health Center as an alternative to the emergency room.
“There has been a noticeable increase in my experience of behavioral health needs in the community over the last five years,” said SMFD Fire Captain Pat Nulty. “I think it’s reached a crisis point, and it’s good to see things happening in the system to address it, and they’re effective, but it’s a large-scale problem.”
Treatment during a 72-hour wait
While on a 5150 hold, patients receive psychiatric and physical evaluations and are often prescribed medication for anxiety, psychiatric disorders, behavior, or acute distress. Patients have the right to refuse medication, except in emergency situations. Physicians may order involuntary medication if they believe the patient lacks reasoning ability, and involuntary treatment may be court-ordered if a patient’s mental illness repeatedly leads to violence or results in criminal detention or hospitalization. Physicians have the ability to file a retention extension of up to 14 days if LPS criteria are still met and patients have the right to contest the extension.
