The Grand Jury and the Doctor

First because his wife is the foreman. Second, because the doctor and his wife, after taking great pains to keep her grand jury work secret, found themselves at the same committee meeting about mental health services at Juvenile Hall.

Third, because subjects of the report have significant implications for our patients and our practices, but was developed with essentially no information from physicians.

Mental Health Services
Most directly related to medical care is the Sacramento County Grand Jury Report of 2000-2001 on "Mental Health Services for Youth Detained in Correctional Facilities." Coming on the heels of the county's losing health services accreditation at its jail, the report underscores the county's failure to meet the health needs of its justice system inmates.

Last year, after touring juvenile correctional facilities, the grand jury decided to examine the care of minors with serious psychiatric problems at Juvenile Hall and other juvenile correctional facilities not equipped to care for them.

The grand jury found that last year's average daily detained population was about 7 percent over bed capacity and that attending physicians, including psychiatrists, estimated that 25 percent of that population needed services for mental illness or other severe psychiatric problems.

On one day, 18 percent were receiving psychotropic medication. Some were suicidal. On that day, Juvenile Hall, with a capacity of 261, was operating at 126 percent of capacity. With a staff of nine providing mental health care, they were unable to provide 24-hour coverage.

In some detention facilities, a psychologist or a social worker provided counseling for crisis management and a nurse administered medications, but no one provided ongoing counseling or psychotherapy.

The report shows even greater shortages in other county juvenile justice facilities. Although juvenile justice has become the county's mental health system of last resort, it is marred by "scarcity of resources, fragmentation of the system, and lack of continuity of services."

Incarcerated minors receive mental health services from the Department of Medical Systems under the Chief Probation Officer. All other minors receive such services from the Director of Mental Health. Each closely guards and separates its funding stream and eligibility, although the minors, along with their symptoms and problems, move from one eligibility status to another.

Dangerous Shortages
The average length of stay in Juvenile Hall is 18 days, but minors with psychiatric problems often need placement in a group home, a halfway house, or other transitional facility. If placement is not available, some minors have been held for more than 400 days - even to 1,000 days - with only minimal treatment in a non-treatment environment. This endangers the safety of all - staff and minors alike.

State law precludes using Medi-Cal funds for persons in correctional facilities, but exempts certain minors awaiting placement. Nevertheless, Sacramento County has not tapped that source, even though Section 11016 of the Welfare and Institutions Code says:

"Notwithstanding any other provision of law, no person for whom federal participation is available shall be denied benefits...solely because such person is incarcerated in a county or city jail or juvenile detention facility."

The jury recommends:

• Raise psychiatric care and treatment of incarcerated minors to the same level as that provided non-incarcerated minors. If that requires changes in Medi-Cal eligibility, the county should seek them.
  
  
• Facilitate agency cooperation and collaboration.
  
  
• Require the county to pursue Medi-Cal funding for health care for minors in detention while awaiting placement.
  
  
• Require a pre-release discharge plan that includes prescription follow-up and other essential follow-up treatment.
  
  
• Require a county review of policies regarding medical and mental health treatment of youth in group homes, correctional facilities, and on probation.
  
  

Call for Psychiatric Hospital
The Grand Jury Report also calls for a 25-bed, free-standing, secure juvenile facility for youth who require acute and subacute care, staffed to meet psychiatric hospital accreditation standards and California Department of Corrections security standards.

Clearly the juvenile justice system needs access to psychiatric beds for acute and subacute care, and clearly some of these beds must be in more secure settings than most juvenile psychiatric patients need. But the findings do not discriminate between those who need acute hospital care and those who need subacute residential treatment. That should be a psychiatric determination, and the grand jury seems not to have asked psychiatrists and other mental health staff in the juvenile justice system for that differentiation or for how they arrived at the 25-bed need.

Sacramento County is already suffering from an unwise policy adopted years ago to favor free-standing over medically integrated psychiatric hospitals. Some of these hospitals are now closed or empty, others are underutilized. This does not show a lack of need, but a lack of funding for a capable staff and a failure to solve the problems that have led to refusing to accept these patients or to releasing them prematurely.

Rather than a new facility that would stimulate a mad dash for scarce staff, the county must define and face its need, make use of the untapped funds already available, and resolve the obstacles to serving these patients well. This could include contracts with existing psychiatric hospitals and residential treatment centers, modified to meet the standards the grand jury has asked for.

Sacramento County must respond to the grand jury report by the end of September. That should not be an ending, but a new beginning. One that has the benefit of advice and assistance from local psychiatrists, pediatricians and the medical society.

More Medically-Related Subjects
Two other subjects of the Sacramento County Grand Jury Report of 2000-2001 have significant medical implications. Both involve the county's foster care program for minors. One deals with "Transitional Assistance for Aging-Out Foster Children" and the other with "Recruitment and Retention of Foster Parents." Physicians who provide professional or personal care for foster children know both problems well.

Again, the numbers are staggering, and Sacramento County's record of foster child turn-over, vying for worst in the state, is pathognomonic of a system failure. Much has already been done to try to correct the failures, with minimal progress and new problems.

The grand jury made many wise recommendations to address these problems, but the one eliciting the most anguished response from the Department of Health and Human Assistance could have been avoided had the grand jury consulted with the medical community.

The grand jury forced a policy choice between "family preservation" and "the best interests of the child." That is a false choice. Children are best served when they are not living in limbo. With rare exceptions, long term foster care is limbo, therefore, the "family preservation" option may be the first best interest of the child; adoption, the second; short foster care, the third.

However, determination of the best all-round interest of the child requires professional staff with experience and judgment, as well as skilled and timely monitoring and fine-tuning of family and child progress. All this is costly.

Sacramento County's exceptionally high rate of children in foster care and unusually long stays in the program result in far too many failed placements, multiple placements, problems with "aging out" foster children, overwhelmed foster parents, and severe mental health problems in Juvenile Hall. All this is costly, too.

Knowledgeable physicians and the medical society might help the county make a new and better beginning.

Please call (916) 874-7559 to request a copy of the grand jury report.

Ed_Rudin@macnexus.org