STOP THE CDCR PRISON SYSTEM TAKEOVER OF 3 CALIFORNIA STATE HOSPITAL PSYCHIATRIC PROGRAMS
• Dear Governor Brown, Lieutenant Governor Newsom, and the California Assembly and Senate—please reconsider and modify legislation in the 2017-2018 budget that would transfer operation of 3 prison-based psychiatric programs from the Department of State Hospitals (DSH) to the California Department of Corrections and Rehabilitation (CDCR) and California Correctional Health Care Services (CCHCS).
• This proposed transfer has been scheduled for discussion at a Joint Hearing of Assembly Budget Subcommittee #1 on Health and Human Services and Assembly Budget Subcommittee #5 on Public Safety on April 3, 2:30 p.m., Room 437 of the State Capitol.
• CDCR has very limited experience in running inpatient psychiatric programs, and one of the two programs that it currently operates, California Institute for Women (CIW), has come under audit by the Joint Legislative Audit Committee (JLAC). The suicide rate at CIW was found to be eight times the national average for women prisoners, and five times the rate for the entire California prison system. Would it be responsible to transfer operation of the 3 DSH facilities to CDCR without waiting for the results of this audit, which are expected in just a few months? Instead, let’s examine the report and stay focused on stopping the epidemic of suicides.
• The CDCR has an abysmal 44% physician vacancy rate. A recent member survey by the Union of American Physicians and Dentists (UAPD) showed that 91% of all DSH psychiatrists and 71% of all CDCR psychiatrists opposed the CDCR takeover of the 3 DSH programs. The CDCR has not shown sufficient ability to recruit and retain physicians, whereas the DSH has done a much better job.
• Psychiatric hospitals shouldn’t be run by administrators who lack experience in healthcare. Please, Governor Brown, don’t make the mistake of putting the care of patients at these 3 critical inpatient facilities at risk, which operate most of the inpatient beds within the California prison system.
• According to CDCR, it does not plan to use Medical Technical Assistant positions in the long run, which would increase cost per bed from $216,000 per year to $301,000 per year—a whopping 39% increase! That doesn’t sound fiscally responsible, does it?
• The Legislative Budget Analyst has recommended that the California Legislature REJECT this proposed transfer and instead shift only a limited number of beds over a three-year period. Please consider this recommendation seriously. Don’t California taxpayers and mentally ill prisoners both deserve better?
From a DSH Staff Psychiatrist
Governor Jerry Brown has proposed in his 2017-2018 budget that on July 1st, 2017, three psychiatric programs currently run by the Department of State Hospitals (DSH), including DSH-Salinas Valley, DSH-Stockton and DSH-Vacaville, will be transferred to the Department of Corrections and Rehabilitation (CDCR) and the California Correctional Health Care Services (CCHCS).
The California Assembly and Senate will consider this proposal over the next few months, and if approved, it would be included in the final budget bill presented to the Governor for his signature. As far as the reason for this transfer, employees were given the following statement from the January 10, 2017, Frequently Asked Questions:
“Over the past several years, CDCR has successfully activated and operated the Psychiatric Inpatient Program (PIP) at the California Institution for Women and the San Quentin Condemned PIP program. CDCR has demonstrated that it is positioned to assume responsibility for the DSH inpatient programs, while ensuring continuity of care to the patients. Additionally, with this transfer, efficiencies will be gained by having all mental health programs under the leadership of one department. It is estimated that patient referral timelines will be reduced, thereby ensuring quicker access to psychiatric care and improving the continuum of care.”
However the evidence does not support the idea that CDCR is ‘successfully operating’ the CDCR Psychiatric Inpatient Programs and is ready to assume responsibility for 3 new programs.
On August 10, 2016, Senator Connie Leyva (D-Chino) announced that there was ‘absolutely a crisis’ at CIW and that the Joint Legislative Audit Committee (JLAC) approved an important audit to examine suicide prevention and reduction policies, procedures and practices at state prisons across California. Senator Leyva’s audit request stemmed from a significant recent increase in the number and rate of suicides at the California Institution for Women (CIW). During an 18-month period in 2014-15, the suicide rate at CIW was found to be eight times the national average for women prisoners, and five times the rate for the entire California prison system.
During this 18-month period, there were four suicides and at least 35 suicide attempts. Prior to 2014 at CIW, there were three suicides total in 14 years. Then in 2016, there were 3 women found dead, all in apparent hangings, including one several months after Senator Leyva’s investigation was announced. However, only one of these deaths has officially classified a suicide by the CDCR. One death involved a 26-year-old woman who was six weeks away from her release date.
From 2013 through April 2016, CIW was reported to have the 3rd most suicides throughout the CDCR, only surpassed by San Quentin at six and Salinas Valley State Prison (note that one of these were within the DSH-run ICF psychiatric program). Based on 2001-2013 data, within overall suicide rate within the California prison system was 21 per 100,000 inmates, whereas the overall US state prison rate was 16 per 100,000. Now the state is paying out millions in settlements following patient deaths.
How does the State of California expect to ever get the prison system out from under federal oversight (and Receivership) if they continue to show a poor track record when it comes to prisoner suicide? Why can’t California get its prison suicide rate down to the US national prison average or lower?
As a Psychiatrist working at DSH-Salinas Valley, I was shocked and saddened to hear about the suicides and investigation at CIW. However, my colleagues and I were outraged that the state would plan for a CDCR takeover the Salinas Valley Psychiatric Program, especially considering that one of the two inpatient programs that the CDCR was running was under an active investigation. At DSH-Salinas Valley, there have been no deaths from suicide from 2014 to 2017, and very few deaths from medical problems. Frankly, I think a much better case could be made that the Department of State Hospitals should be taking over all inpatient programs within the CDCR, instead of the reverse.
The report on Senator Leyva’s investigation isn’t expected until June 2017. So why should the California Governor, Legislature, and Senate approve the CDCR takeover of 3 additional inpatient psychiatric programs, before the report on the suicides and CIW and CDCR facilities is even released?
In my opinion, the reason for fewer deaths at our facility can be attributed to much better staffing and operating methods within the DSH programs. At the facility where I work, DSH-Salinas Valley, I believe that a lot of the credit should go to the Medical Technical Assistants (MTAs), Rehabilitation Therapists (RTs), Licensed Social Workers (LSWs), Licensed Psychiatric Technicians (LPTs), Staff Psychologists, Staff Psychiatrists, Physician/Surgeons, and Registered Nurses (RNs). Unfortunately, outside of the 3 DSH facilities, the rest of the CDCR does not even have Medical Technical Assistants (MTAs), and non-medically, non-psychiatrically trained Correctional Officers (COs) are asked to fulfill many of the roles that MTAs provide at our facility. MTA positions were eliminated across all of the CDCR about a decade ago, much to the detriment of patient health, in my opinion—and MTA positions in the DSH are at risk of elimination if the CDCR takes over the 3 DSH psychiatric programs as planned. A previous CDCR Receiver cited millions of dollars in taxpayer savings as the primary reason for eliminating all MTA postions. However the Legislative Budget Analyst believes having MTAs under DSH management actually saves money:
“For example, DSH uses Medical Technical Assistants (MTAs) that combine nursing and custody responsibilities, which prevent the need for hiring two separate staff members for these functions. According to CDCR, it does not plan to use MTA positions in the long run, which would increase costs. Moreover, the cost per bed of the units currently operated by CDCR is $301,000 per year—well above the $216,000 cost per bed for the in-prison programs operated by DSH…. Given the significant uncertainty on whether the proposed shift in responsibility would result in more cost-effective care being delivered, we recommend that the Legislature reject the Governor’s proposal and instead shift a limited number of beds over a three-year period.”
As far as staff recruitment and retention of physicians, our psychiatry department at DSH Salinas Valley has been nearly fully staffed since 2014, and we also have had 3 to 4 primary care physician/surgeons during this time. By comparison, our CDCR sister facility, Salinas Valley State Prison (SVSP), was cited in a 2016 report for having inadequate access to medical care record with notably poor physician staffing.
On March 20th, 2017, the Union of American Physicians and Dentists (UAPD) wrote the inmates’ attorneys to express severe concern about the poor levels of physician staffing within the CDCR, including an abysmal 44% physician vacancy rate. The UAPD asserts that there is a severe psychiatrist shortage within CDCR and that the state is doing too little to correct it. Of those answering the survey, the report showed that 91% of all DSH psychiatrists and 71% of all CDCR psychiatrists opposed the CDCR takeover of the 3 DSH programs (referred to as the ‘Lift and Shift’).
One the union survey, one CDCR psychiatrist at CIW noted, “…We had a rash of suicides, were understaffed at the time, and morale was horrendous….” A DSH psychiatrist stated bluntly, “CDCR has a proven record of providing poor healthcare, poor psychiatrist retention, staff burnout, poor management skills.”
Sadly, I would agree that the CDCR has not shown an ability to recruit and psychiatrists or primary care physician/surgeons. I would also say that CDCR system is run too much like the prison system and not enough like community psychiatric clinics or hospitals. As far as physician retention, the CDCR operates with a quasi-military rank system—but unlike in actual US military, staff psychiatrists, physician/surgeons, and staff psychologists are given no rank—and almost no opportunity for organizational input or decision-making. And psychiatrists who have worked at prison-based facilities describe a more punitive administrative culture, prone to more frequent use of progressive disciplinary action for employees (‘Letters of Instruction’ or such), which does not help retain staff (especially physicians).
I fear the effect that a CDCR takeover could have on these three critical psychiatric programs as far as staffing, safety, and suicide rate. And I hope the wisdom of this proposed change is seriously reevaluated.
Joel Badeaux, MD, MPH Department of State Hospitals – Salinas Valley Staff Psychiatrist & Psychiatry Committee Chair
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