Adult Psychiatric Bed Capacity, Need, and Shortage Estimates in California—2021

Short abstract

This article presents an evaluation of California's psychiatric bed needs in 2021 and the coming years. California, like many states, is confronting a psychiatric bed shortage. To strategically build capacity, the state must understand its psychiatric bed needs. The authors examine California's adult bed capacity, need, and the gap between them at three levels of inpatient and residential care: acute, subacute, and community residential services.

Abstract

Psychiatric beds are essential infrastructure for meeting the needs of individuals with mental health conditions. However, not all psychiatric beds are alike: They represent infrastructure within different types of facilities, ranging from acute psychiatric hospitals to community residential facilities. These facilities, in turn, serve clients with different needs: some who have high-acuity, short-term needs and others who have chronic, longer-term needs and may return multiple times for care. California, much like many parts of the United States, is confronting a shortage of psychiatric beds. In this article, the authors estimated California's psychiatric bed capacity, need, and shortages for adults at each of three levels of care: acute, subacute, and community residential care. They used multiple methods for assessing bed capacity and need in order to overcome limitations to any single method of estimating the potential psychiatric bed shortfall. The authors identified statewide shortfalls in beds at all levels of inpatient and residential care. They also documented regional differences in the shortfall and identified special populations that contributed to bottlenecks in the continuum of inpatient and residential care in the state.

Psychiatric beds are essential infrastructure for meeting the needs of individuals with mental health conditions. However, not all psychiatric beds are alike: They represent infrastructure within different types of facilities, ranging from acute psychiatric hospitals to community residential facilities. These facilities, in turn, serve clients with different needs: some who have high-acuity, short-term needs and others who have chronic, longer-term needs and may return multiple times for care.

California, like many parts of the United States, is confronting a shortage of psychiatric beds. This shortage manifests in high bed occupancy rates and long wait lists for placements. However, determining the primary drivers of this shortage—accounting for regional variation in psychiatric bed capacity at different levels of care—is a challenging problem to tackle. Nevertheless, California is committed to expanding the mental health infrastructure, including psychiatric bed capacity. How, where, and to what extent these investments should be made remains an open question.

In this study, we estimated psychiatric bed capacity, need, and shortages for adults at each of three levels of care throughout California. These three levels of care are acute, subacute, and community residential services:

• Acute care is directed toward those with the highest acuity needs, is typically shorter term (days to weeks), and is intended to stabilize patients.

• Subacute care is directed toward those with moderate- to high-acuity needs for a longer duration (multiple months).

• Community residential services are intended to address lower acuity and longer-term care (often multiple years) that is focused on patient recovery.

We computed these estimates with and without the inclusion of state hospitals, which often provide care for unique subpopulations who may be hard to place in other settings, including those with high acuity, long-term needs. Additionally, we projected growth in the need for psychiatric beds in the period of 2021 to 2026.

Approach

Our population of interest comprised adults (18 years or older) throughout California. The corresponding sampling frame contained all psychiatric facilities with psychiatric beds serving adults throughout California's 58 counties. Because individuals might access psychiatric facilities (and beds) outside their county of residence, we aggregated estimates at a regional level using the U.S. Census Bureau classification.

To estimate psychiatric bed capacity, we synthesized an array of data sets from state agencies that are responsible for licensure of psychiatric beds. To supplement this information, we employed a stratified randomized sampling approach to administer a survey to collect data on the number of beds at facilities and the number of beds occupied. We provided estimates to county points of contact at behavioral health departments to review and revise them with an eye to improving accuracy.

To estimate psychiatric bed need, we used several approaches for the purpose of triangulation. First, we contacted psychiatric facilities throughout the state and spoke with administrative leaders at these facilities to quantify bed occupancy rates, wait list volume, average length of stay, and the number of individuals whom they would transfer to a higher or lower level of care if able to do so. Using the information gathered, we were able to compute the number of beds required—at each level of care in each region of the state—to reduce occupancy rates to 85 percent (a standard ceiling) and accommodate wait list volume and requested transfers. We calculated these estimates excluding state hospitals and, separately, including state hospitals, prioritizing the former approach. Our rationale for this is that state hospital beds are generally not considered part of the continuum of care at a local level in terms of decisionmaking purposes. Second, we moderated this bottom-up estimate by incorporating epidemiological information on regional variation in serious psychological distress (SPD) among adults, which serves as an indicator of psychiatric bed need. Third, as a top-down approach, we convened a Technical Expert Panel to deliberate and arrive at normative estimates of psychiatric bed need available from the research literature.

Lastly, we projected the need for psychiatric beds in the period from 2021 to 2026. To accomplish this, we first quantified the prevalence of SPD according to demographic categories (i.e., sex, race/ethnicity, and age group) among adults in California, using the California Health Information Survey. From this, we were able to estimate the regional prevalence of SPD in 2026, based on evolving demographic trends. Next, we cross-walked the estimated prevalence of SPD to the likelihood of requiring inpatient psychiatric services, based on the proportional need for inpatient psychiatric services among individuals with versus without SPD, according to the National Survey on Drug Use and Health (NSDUH).

Key Findings

• California faces an estimated 1.7-percent growth in its psychiatric bed need from 2021 to 2026.

• California faces shortages of psychiatric beds at all three major levels of adult inpatient and residential care.

• Significant regional differences in the estimated shortfall of beds were noted at each level of care.

• Growth in the need for psychiatric beds is projected to be largest in the Northern and Southern San Joaquin Valley.

• Hard-to-place populations contribute disproportionately to bottlenecks in the existing system.

• A majority of psychiatric facilities at all levels of care reported an inability to place individuals with comorbid dementia or traumatic brain injury, nonambulatory individuals, those requiring oxygen, and those who tested positive for COVID-19. Individuals involved in the criminal justice system were reportedly difficult to place in community residential settings.

Psychiatric bed capacity. We estimated that California has a total of 5,975 beds at the acute level (19.5 per 100,000 adults) and 4,724 at the subacute level (15.4 per 100,000 adults)—excluding state hospital beds. If state hospital beds are included, these figures increase to 7,679 (25.1 per 100,000 adults) and 9,168 beds (29.9 per 100,000 adults), respectively. We also observed large regional variation. For example, excluding state hospitals, acute bed capacity ranged from 9.1 beds per 100,000 adults in the Northern San Joaquin Valley to 27.9 beds per 100,000 adults in the Superior region. For subacute bed capacity, regional estimates ranged from 7.4 to 31.8 beds per 100,000 adults. At the community residential level, we estimated that California has a total of 3,872 beds (12.7 per 100,000 adults).

Psychiatric bed need. Using observed occupancy rates, wait list volumes, and requested transfers, we estimated that California requires 50.5 inpatient psychiatric beds per 100,000 adults: 26.0 per 100,000 at the acute level and 24.6 per 100,000 at the subacute level, or 7,945 and 7,518 beds, respectively. At the community residential level, we estimated a need of 22.3 beds per 100,000 adults.

Estimated prevalence of SPD in California ranged from 7.9 percent in the San Francisco Bay Area to 9.3 percent in the Southern San Joaquin Valley. When we incorporated this epidemiological information into our psychiatric bed need estimates, this introduced regional variation in psychiatric bed need that ranged from 45.5 to 55.5 inpatient psychiatric beds per 100,000 adults. Lastly, we collected secondary estimates of psychiatric bed need from the academic literature and our Technical Expert Panel. Using median values, we generated a separate, top-down estimate of psychiatric bed need: 27.5 beds per 100,000 adults at the acute level and 25 per 100,000 at the subacute level. We were unable to provide a comparable top-down estimate of need for community residential beds because of the significant heterogeneity within this classification and the paucity of academic literature.

We estimate that the magnitude of need for psychiatric beds is expected to grow modestly over the next five years (2021 to 2026): by 1.7 percent. This is primarily due to shifting demographic trends, including adult population growth and increasing racial/ethnic diversity, because epidemiological data indicate that Hispanic and Black adults experience SPD at higher rates than do White adults. Growth in the need for psychiatric beds is projected to be largest in the Northern and Southern San Joaquin Valley—by about 4.0 percent.

Psychiatric bed shortages. Synthesizing figures for bed capacity and bed need, we estimated that the state has a shortfall of approximately 1,971 beds at the acute level (6.4 additional beds required per 100,000 adults) and a shortage of 2,796 beds at the subacute level (9.1 additional beds required per 100,000 adults)—or 4,767 subacute and acute beds combined, excluding state hospital beds. If state hospitals were included in this estimate, the shortage of acute inpatient beds would shrink to 267, and there would be no observable shortage in beds at the subacute level. Separately, we estimated a shortage of 2,963 community residential beds.

The top-down estimates of psychiatric bed need—as drawn from the literature and our Technical Expert Panel—also indicated a bed shortage: 8.9 beds per 100,000 adults at the acute level and 10.6 beds per 100,000 adults at the subacute level. Therefore, our bottom-up and top-down estimates were closely aligned. The remaining discrepancy likely pertains to differences in the configuration of health systems throughout the United States and internationally, including availability of outpatient services and alternatives to hospitalization, that drive need.

When regional prevalence estimates for SPD were incorporated, the gap in beds required reduced modestly: by 4.5 percent. We also documented significant regional differences in the estimated shortfall of beds on the basis of the wide regional variation in psychiatric bed capacity. For example, two regions of the state appear to have sufficient acute inpatient psychiatric bed capacity, whereas the remaining eight regions have a shortfall. At the subacute level, all regions (apart from the Northern San Joaquin Valley) appear to have a shortfall. However, the magnitude of this shortfall ranges from 5.1 additional beds required per 100,000 adults in the North Coast region of the state to 17.2 additional beds required per 100,000 adults in the Southern San Joaquin Valley.

Lastly, we inquired about hard-to-place populations. Here, we found that a majority of psychiatric facilities at all levels of care reported an inability to place individuals with comorbid dementia or traumatic brain injury, nonambulatory individuals, those requiring oxygen, and those who tested positive for the coronavirus disease 2019 (COVID-19). A majority of respondents from community residential facilities also reported an inability to place individuals involved in the criminal justice system—particularly those with arson or sex offense convictions.

Recommendations

Using these findings, we came up with three recommendations:

1. Prioritize psychiatric bed infrastructure in the areas with the greatest need. In terms of an absolute shortfall of beds, the shortfall was greatest in terms of subacute beds, driven partly by four regions (Los Angeles County, San Francisco Bay Area, Inland Empire, Superior region) that represented a shortfall of more than 2,000 beds—more than a quarter of all additional beds needed throughout the state. If policymakers examine the psychiatric bed shortfall as a proportion of regional adult population, this might lend greater weight to regions with smaller or more rural populations: For example, the shortfall of subacute beds is 5.2 beds per 100,000 adults in Los Angeles County compared with 17.2 per 100,000 adults in the Southern San Joaquin Valley. We also observed significant need for acute beds in such regions as the Northern and Southern San Joaquin Valley and Central Coast, while the shortfall at the community residential level was particularly notable in such regions as the Central Coast, Inland Empire, and Southern San Joaquin Valley.

2. Consider focusing on building or remodeling infrastructure for the most hard-to-place populations. Specific subpopulations appear to contribute disproportionately to bottlenecks in the current system, including an inability to transfer patients with criminal justice involvement from the subacute level of care to community residential settings. Given this, the state might need to consider alternative arrangements for placing such populations, such as community-based and outpatient competency restoration programs. Here, California could learn from other mental health systems across the United States and internationally.

3. Set aside state funds for a system that reviews licensure data and periodically collects psychiatric facility–level information. Our analysis and conclusions contain numerous caveats, in large part because of poor data quality. We wish to be transparent about this fact, with the hope that this serves as an impetus for the state to consider investing in an adequate data review and monitoring system. If the state were to allocate funds to routinely monitor and purge licensure data, policymakers would be in a much stronger position to know what the existing capacity is at each level of care—particularly at the community residential level. Likewise, the state should consider establishing a mechanism by which psychiatric facilities report periodically on bed occupancy rates, wait list volume, number of requested transfers to higher and lower levels of care, and psychiatric patient boarding in emergency departments. The state should also consider collecting sociodemographic and clinical information on patients who use psychiatric beds. This would allow California to have a remarkably precise and sensitive system for tracking the impact of investments that seek to address psychiatric bed shortages.