Bo Hu, MD MS. Assistant Professor of Psychiatry, UCSF Health 

Misti Meador, Assistant Director of Post Acute Care 

Patients with psychiatric needs on the medical floor are often dispositionally and legally complex. This not only leads to longer stays on acute/transitional care beds with minimal interventions, but also provides a suboptimal environment of care for chronically underserved patients. Exacerbating the situation, recent legal and institutional changes will increase the volume of patients who fit criteria for holds and conservatorship, further placing strain on the system. Therefore, we propose a dedicated mental health navigator across the UCSF acute care system, with the goal of decreasing length of stay by coordinating legal and dispositional services in complex adult patients with mental illness. This role would also allow medical staff and social work to operate at the highest scope of practice. 

Bo Hu, Consultation Liaison Psychiatrist, Officer of Quality Improvement in Psychiatry (project lead) 

Erik Levinsohn, Consultation Liaison Psychiatrist 

Larry Kaplan, Service Director of Consultation Liaison Psychiatry 

Ramotse Saunders, Medical Director of Acute Services, Psychiatry 

Manisha Israni-Jiang, Clinical Professor, Internal Medicine and Pediatrics 

Quinny Cheng, Medicine I Social Worker Medical Director 

Misti Meador, Assistant Director of Post Acute Care 

Kelley Ogami, Medicine I Social Worker 

Nerys Benfield (Executive Sponsor) 

UCSF Mental Health Navigator, Assignment TBD 

Nurses at Parnassus are unable to coordinate with legal team at Mt. Zion to allow conversation with patients prior to hearings 

Residents and attendings are asked to provide logistical assistance, such as setting up a zoom call on a smartphone or iPad to mediate the conversation between the legal team and the CL psychiatry team 

Occasionally, a member of the Parnassus CL team has had to physically travel to Mt. Zion to pick up a physical hold paperwork because the hold was signed by the legal team at Mt. Zion 

Senate Bill 43 (SB43)has broadened the criteria for LPS holds: 

Conservatorship of patients with substance use disorders  

Expansion of grave disability criteria to includethe inability to provide personal safety and/or necessary medical care 

Eating disorder patients will likely require LPS holds in the UCSF system 

Transfer to inpatient psychiatry facilities, which have limited availability and may accept or reject patients based on institution-specific requirements 

Transfers to special treatment programs, such as partial hospitalization programs, intensive outpatient programs, or residential treatment programs 

Mental health outpatient referrals, both internal to UCSF and external 

Filing for conservatorship, which requires intensive coordination and expertise with regional legal statutes. Many of these time-intensive tasks are left to house staff, who have limited training in facilitating these outcomes and are drawn away from providing consultation to primary teams 

Results lead to delayed treatments or sometimes inability to offer patients ECT, thereby worsening patient outcomes or delaying discharge 

UCSF Adult Financial Services estimates the direct cost of providing care for patients who no longer require inpatient interventions to be $1688 per day in 2024 on the med/surg and transitional care beds. 

674 psychiatry consultations on med/surg beds 

379 holds and conservatorship orders on med/surg beds 

195 5250s/5260s/5270s (requires hearings) 

27 Temporary and Permanent Conservatorships filed 

156 of 379 of patients on holds and conservatorships went to a disposition that was not home care 

A range of 4-7 patients per year who receive ECT on the medical floors annually 

An estimated range 3-8 patients (varies based on diagnosis of anorexia nervosa vs failure to thrive / ARFID) per year which may require LPS holds in the future 

This does not include patients who are not on holds, who also require close coordination with social work and case management 

There are multiple systems barriers to care forthis patient population 

Patients in our target population are vulnerable due to their cognitive impairment, age and psychosocial barriers. Many have substance use or mental health disorders and are often homeless without support for medication management and activities of daily living support.  

Acute medical units are not conducive to the care of the elderly, cognitively impaired or patients with mental health disorders. Being restricted to their rooms due to the concern of elopement or harm to staff or themselves can contribute to their agitation. 

The legal process of conservatorship or Medi-Cal insurance acquisition is long drawn and a systems issue outside the scope of UCSF Health 

There is reduced availability of inpatient psychiatric beds and community resources especially for uninsured or Medi-Cal patients 

Helping MD/SW team with conservatorship paperwork and logistics 

Scheduling and coordinating probable cause LPS hearings with legal team 

Legal documentation management, such as storing hold/RIESE/conservatorship paperwork 

Accelerating voluntary/involuntary ECT paperwork and coordination 

Assisting SW with inpatient psychiatry referrals 

Helping with finding outpatient disposition within and outside of the UCSF health system 

Obtaining collateral from patients and records from outside hospitals, which can accelerate treatment planning and initiation 

Liaising between patients, families and for improved quality and speed of communication, improving patient experience 

Allowing house staff and SW to practice at maximum scope 

For example, SW can eventually participate in probable cause hearings as in other institutions in California