H9

Office of the President

TO MEMBERS OF THE HEALTH SERVICES COMMITTEE:

DISCUSSION ITEM

For Meeting of December 10, 2019

BEHAVIORAL HEALTH COLLABORATION, CAMPUS

EXECUTIVE SUMMARY

UCSD Health, San Diego County, and Scripps Mercy have been involved in discussions to create short- and long-term solutions for inpatient behavioral health in central San Diego. Discussions have included the proposals that (1) UCSD assume management of the current, locked inpatient San Diego County Psychiatric Hospital (located on Rosecrans Street in San Diego) and that the Rosecrans facility be placed under UCSD Health’s general acute care hospital license and (2) the development of a new locked inpatient psychiatric facility on County-owned land less than a half-mile from both UCSD’s Hillcrest Hospital and to operate as a central “hub” for behavioral health services in central San Diego. This site and various operational models are now being evaluated along with UCSD’s management of the County’s Rosecrans facility. The parties are also discussing how to link services at these facilities to on-site Crisis Stabilization Units and post-inpatient care services such as intensive outpatient services, primary care, substance use disorder services, and supportive services such as recuperative housing.

BACKGROUND

The need for mental health services in San Diego far outstrips the resources that are available to serve these patients, especially for patients lacking commercial insurance. This, combined with historical payment models that do not allow for sufficient investment in behavioral health infrastructure, has created a crisis in services, especially for those classified with severe mental illness.

In central San Diego, there are three inpatient facilities serving this population: the 60-bed San Diego County Psychiatric Hospital (the Rosecrans facility), a Scripps Mercy Hospital inpatient unit of 36 beds, and UC San Diego Hillcrest, with 32 beds—14 for geropsychiatric care for older patients within the hospital itself, and 18 beds for other patients in a neighboring facility called the West Wing.

The West Wing was built over 40 years ago and has reached the end of its useful life. This facility and most of the rest of the Hillcrest Campus facilities are planned for replacement as part HEALTH SERVICES COMMITTEE -2- H9 December 10, 2019

of the 2019 Long Range Development Plan, which has been approved by the Regents. Until last year, the redevelopment of Hillcrest Campus was complicated by the fact that the hospital and land was originally owned by the County. In return for the County lifting specific land-use deed restrictions, UC San Diego Health agreed to pursue potential solutions for inpatient behavioral facilities serving central San Diego in combination with the County.

For the past year, UC San Diego Health and San Diego County have been involved in discussions to create short- and long-term solutions for inpatient behavioral health for central San Diego. Discussions originally revolved around UCSD assuming management of the Rosecrans facility and putting it under UCSD Health’s general acute care hospital license in order to remove the Centers for Medicare and Medicaid Services (CMS) Institutions for Mental Diseases (IMD) exclusion and allow the facility to be reimbursed for care of patients under Medicaid/Medi-Cal. The dollars gained by the collaboration would then be reinvested in other mental health services in the county.

More recently, Scripps Mercy Hospital has recognized that it, too, has a need for replacement inpatient beds in the Hillcrest area to serve mostly Medi-Cal patients. This comes after it has announced a partnership with a for-profit provider to create a 120-bed facility in Chula Vista, approximately 15 miles away (30-45 minutes travel time). This facility will serve predominantly commercially insured patients, from central San Diego and beyond.

A long-term inpatient facility solution for central San Diego has recently been identified by the County as part of the creation of behavioral health “hubs” (see below). County-owned land on Third Avenue, less than a half-mile from both Hillcrest and Mercy , could be a viable location for a locked inpatient psychiatric facility. This site and operational models are now being evaluated along with management oversight of the original Rosecrans location.

County leadership is becoming increasing engaged in these ongoing discussions. The new Director of Behavioral Health Services for San Diego County, Luke Bergmann, Ph.D., has brought new ideas and new energy to finding collaborative solutions for the county’s most vulnerable. Additionally, the new County Supervisor for District 4 that encompasses Hillcrest Campus, Nathan Fletcher, has been an enthusiastic and involved leader on this issue. This energy has created new opportunities for collaboration and investment in this area, and UC San Diego Health is keen to be a part of these efforts.

The Opportunity

All three potential collaborators, UC San Diego Health, Scripps Health, and San Diego County, have the opportunity to create a comprehensive approach to addressing behavioral health care needs for central San Diego through a collaborative partnership. Not only will it involve inpatient care facilities at Rosecrans and Third Avenue, but, as currently envisioned, link those services to on-site Crisis Stabilization Units (CSUs) and post-inpatient care services such as Intensive Outpatient Services, primary care, substance use disorder services, and supportive services such as recuperative housing. The County is working with other health systems in other, geographically dispersed, parts of the county make these “hubs” come to life as part of an integrated network of care, with the central hub potentially the first to be constructed. HEALTH SERVICES COMMITTEE -3- H9 December 10, 2019

Not only can these hubs be a model for clinical care, but they also afford the opportunity to develop additional capabilities in support of behavioral health for the greater San Diego region. As currently envisioned, these hubs could be part of a larger workforce development effort led by UC San Diego’s Department of Psychiatry in coordination with other training institutions in the area. There is also an opportunity to connect this work with other efforts at UC San Diego’s School of around substance use disorder treatment and research and the upcoming School of Public Health at UC San Diego.

This work will also create new opportunities for both State and national grants and partnership with local, State, and national foundations. Opportunities for philanthropy in areas related to these hubs are currently being pursued.

In sum, this development opportunity encompasses not only brick-and-mortar development of facilities to treat the underserved, but also to have UC San Diego bring leadership in clinical innovation, research, and workforce development to an area where it is uniquely qualified.

Key Challenges / Discussion Points

Development and operation of behavioral health facilities are challenging, even as a single entity. Combining two governmental entities along with a non-profit health provider will make this effort much more challenging from a governance, financial, and operational standpoint. However, a scaled, coordinated approach has long been needed in San Diego and is critical for tackling these incredibly challenging societal challenges. The leadership of UC San Diego Health is committed to finding a solution that works for all parties and serves those in the San Diego community in need of these services.

From the perspective of the University of , UC San Diego, and UC San Diego Health, there are many challenges that will need to be addressed in this collaboration:

Reputational Risk – Working with patients with severe mental illness means there will always be challenges in maintaining 100 percent patient safety, even with complete focus and all resources in place. All organizations involved will need to take the appropriate responsibility.

Financial Sustainability – Reimbursement for Medi-Cal inpatients rarely covers ongoing operating costs. While there is the possibility of rate adjustments through the County to better cover operational costs, the future collaboration will need to address financial risk in a way this is acceptable to all parties.

Financial Impact to UCSD Health – While the development terms of a potential Third Avenue site are yet to be determined, care will need to be taken with regard to potential impacts to bond ratings, should there be capital investments. Additionally, an increase in the volume of Medi-Cal patients may require adjustments to Disproportional Share Hospital (DSH) financials since both the Rosecrans and Third Avenue facilities would be under UCSD Health’s general acute care hospital license.

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Operational Considerations – Since the Rosecrans and Third Avenue sites are planned to be under UCSD Health license, there are operational factors regarding staffing of the sites, including nursing and physician staffing, that will need to be taken into account. It will be important to consider potential impacts to represented and non-represented staff across all parties and to consider the current Nurse Magnet status for the Hillcrest Hospital.