Psychiatric and Substance Use Disorder Bed Capacity, Need, and Shortage Estimates in Sacramento County, California

Key Findings

• Although some treatment facilities appear to have stable bed occupancy rates and short waitlist volumes, their beds are not always available to individuals in need of services.
• In terms of psychiatric beds, need is particularly urgent at lower levels of care; for substance use disorder (SUD) treatment beds, urgency of need is most pronounced for Sacramento County residents who are insured by Medi-Cal.
• At SUD treatment facilities, more than one-quarter of beds were occupied by out-of-county patients.
• Using statewide or national benchmarks, Sacramento County would need more than 100 SUD treatment beds for adults and another 30 to 40 beds for children/adolescents.

Introduction

Psychiatric and SUD treatment beds are essential infrastructure for meeting the needs of individuals with behavioral health conditions. However, not all psychiatric and SUD treatment beds are alike: They represent infrastructure within different types of facilities. For psychiatric beds, these vary from acute psychiatric hospitals to community residential facilities (McBain, Cantor, and Eberhart, 2022). For SUD treatment beds, these vary from facilities offering short-term withdrawal management services to others offering longer duration residential detoxification services (California Department of Health Care Services, 2022). Different settings also serve clients with different needs. For example, some clients have high-acuity, short-term needs; others have longer-term needs and may return for care on multiple occasions.

Sacramento County, much like other counties throughout the United States, has been seeking to assess shortages in psychiatric and SUD treatment beds (Sacramento County Mental Health Board, 2019; Technical Assistance Collaborative and Human Services Research Institute, 2012). This effort has been closely timed with California's commitment to expand behavioral health infrastructure and bed capacity. Our previous study examined California's statewide and regional psychiatric bed needs, but we did not examine need for specific counties, such as Sacramento County (McBain, Cantor, and Eberhart, 2022).

In this study, we estimated psychiatric bed and residential SUD treatment capacity, need, and shortages for various levels of care within Sacramento County. For our analysis of psychiatric beds, we included three levels of care: acute, subacute, and community residential services. Acute care is directed toward clients with the highest-acuity needs, is typically shorter term (days to weeks), and is intended to stabilize patients; subacute care is directed toward clients with moderate- to high-acuity needs for a longer duration (multiple months); and community residential services are intended to address lower-acuity needs and longer-term care (often multiple years) that is focused on patient recovery. For our analysis of SUD treatment services, we used service categories as defined by the American Society of Addiction Medicine's (ASAM's) clinical guidelines (American Society of Addiction Medicine, undated). These included residential detoxification services (ASAM level 3.2); residential long-term treatment, which is typically more than 30 days (ASAM level 3.3); and residential short-term treatment, which is typically 30 days or fewer (ASAM level 3.5).

Approach

Our population of interest comprised all adults (18 years and older) and children/adolescents throughout Sacramento County. We therefore sought to conduct a phone-based survey with administrators at every psychiatric and SUD treatment facility in Sacramento County that provided inpatient services.

To estimate bed capacity, we synthesized an array of data sets from state agencies that are responsible for the licensure of psychiatric and SUD treatment beds into a list, which we updated based on feedback from the county's Department of Health Services. To supplement this information, we administered a phone-based survey through which we contacted all psychiatric and SUD treatment facilities in Sacramento County to collect data bed occupancy rates, waitlist volume, and requested transfers to higher and lower levels of care.

To estimate psychiatric and SUD treatment bed need, we used triangulated estimates from multiple approaches. First, as noted above, we contacted psychiatric and residential SUD treatment facilities throughout the county and spoke with administrative leaders. Drawing on the information that we gathered, we were able to compute the number of beds required—at each level of care in Sacramento County—to reduce bed occupancy rates to 85 percent (a standard ceiling), as well as accommodate waitlist volume and requested transfers. Second, we conducted an environmental scan of academic and gray literature to identify normative and descriptive benchmarks for psychiatric and SUD treatment bed capacity and need. This allowed us to compare bottom-up estimates of need, based on observed outcomes at facilities in Sacramento County, with top-down estimates of need based on thresholds outlined by experts or otherwise established in various jurisdictions at local, national, and international levels.

Key Findings

Psychiatric bed capacity. We estimated that Sacramento County has a total of 593 adult beds at the acute level (48.8 per 100,000 adults) and 82 adult beds at the subacute level (6.8 per 100,000). At the community residential level, we estimated that the county has a total of 262 adult beds (21.6 per 100,000). For children/adolescents, we found 147 psychiatric beds (39.7 per 100,000) in total: 113 beds at the acute level (30.5 per 100,000 children/adolescents), 0 at the subacute level, and 34 at the community residential level (9.2 per 100,000).

SUD treatment bed capacity. We identified 415 adult beds in Sacramento County: 238 beds available for clinically managed, high-intensity residential services (19.6 per 100,000 adults; ASAM level 3.5); 192 available for clinically managed, moderate- to low-intensity residential services (15.8 per 100,000 adults; ASAM level 3.3); and 79 available for clinically managed residential detoxification services (6.5 per 100,000 adults; ASAM level 3.2). We also estimated that there are 12 child/adolescent SUD treatment beds.

Psychiatric bed need. Using facility survey responses, we estimated that Sacramento County requires 251 adult acute inpatient psychiatric beds (20.7 per 100,000 adults) and 335 at the subacute level (27.6 per 100,000 adults). At the community residential level, we estimated a need of 302 beds (24.9 per 100,000 adults). Drawing on our review of the literature,¹ we compared these estimates with a similarly reported need of 315 adult acute inpatient psychiatric beds (26.0 per 100,000 adults), 298 subacute beds (24.6 per 100,000 adults), and 271 community residential beds (22.3 per 100,000 adults). Although we did not have a sufficient number of survey responses to estimate child/adolescent psychiatric bed need, our review of descriptive benchmarks of bed capacity indicated a range from 30 to 34 acute beds (8.1 to 9.2 per 100,000 children/adolescents), 28 to 32 subacute beds (7.7 to 8.7 per 100,000 children/adolescents), and 98 to 164 community residential beds (26.3 to 44.3 per 100,000 children/adolescents).

SUD treatment bed need. Using facility survey responses, we estimated that Sacramento County requires 417 adult SUD treatment beds (34.7 per 100,000 adults). There was greater demand for higher-intensity services: Beds for ASAM levels 3.5 and 3.3 had higher occupancy rates, and there were more requests for transfers to higher levels of care compared with requests for transfers to lower levels of care. Drawing from our review of the literature, we found that reference benchmarks for adult SUD treatment beds were considerably higher: about 518 to 561 beds (42.7 to 46.2 per 100,000 adults). Among children/adolescent-servicing facilities, we did not receive enough survey responses to directly estimate SUD treatment bed needs. However, using our review of the literature, we found reference benchmarks of 37 to 58 SUD treatment beds (9.9 to 15.6 per 100,000 children/adolescents).

Psychiatric bed shortage. We estimated that Sacramento County has a surplus of 342 adult beds at the acute level. We also estimated that Sacramento County has a shortage of 253 subacute beds and 40 community residential beds. Using statewide and international reference points for child/adolescent psychiatric beds, we observed a similar—albeit smaller—surplus of acute beds; however, there was a shortfall of 28 to 32 beds at the subacute level and a considerably larger shortfall at the community residential level (between 64 and 130 beds).

SUD treatment bed shortage. We estimated that Sacramento County has a shortfall of 146 adult SUD beds. This is 12.0 beds per 100,000 adults shy of California's average rate of 46.2 beds per 100,000 adults. This also represented a shortfall of 103 adult SUD beds compared with the U.S. national average (8.5 beds per 100,000 adults shy of the national average of 42.7 beds per 100,000 adults). Using facility survey responses, we estimated a considerably smaller shortage; however, this direct estimate likely underestimates the magnitude of the shortage because more than one-quarter of beds were occupied by clients from outside Sacramento County and more than one-half of facilities did not accept Medi-Cal patients. Both of these factors could be contributors to our results. Among child/adolescent SUD beds, we found that the California and national benchmarks indicated a shortfall of 25 to 46 beds (6.7 and 12.4 per 100,000 children/adolescents, respectively).

Difficult-to-place populations. Overall, we found that the most-difficult-to-place populations at psychiatric facilities were individuals with dementia (0 percent of facilities accepted such individuals), nonambulatory individuals (0 percent), and individuals who required oxygen (8 percent). The most-difficult-to-place populations at SUD treatment facilities were individuals with a past sex offense (5 percent of facilities accepted such individuals), nonambulatory individuals (21 percent), and individuals with an arson conviction (21 percent).

Recommendations

Drawing on these findings, we offer the following three recommendations:

1. In terms of psychiatric beds, focus on addressing the shortage of beds at lower levels of care. Sacramento County appears to have sufficient acute psychiatric beds for adults and (potentially) children/adolescents. However, we estimated that the county requires about 300 additional beds at subacute and community residential levels for these populations. One potential solution to increase the number of beds at these lower levels of care might be to expand infrastructure. However, this could lead to an overall surplus—including of unused infrastructure—if even more patients were transferrable from acute to lower levels of care. Sacramento County may therefore want to consider alternatives that allow the county to shift the existing distribution of beds from higher to lower levels of care.
2. In terms of SUD treatment beds, focus on beds that are available for Sacramento County residents who are currently difficult to place—including Medi-Cal recipients. We observed that more than one-quarter of SUD treatment beds are occupied by residents from outside Sacramento County and that fewer than one-half of facilities accepted patients insured by Medi-Cal. This indicates that, although these facilities appear to have stable bed occupancy rates and short waitlist volumes, beds at these facilities are not available to many individuals in need of services. This observation may also account for the difference in the estimated need for SUD treatment beds in Sacramento County based on (1) observed outcomes from survey interviews and (2) the reference benchmarks of statewide and national bed capacity. If Sacramento County were to anchor on reference benchmarks (which we believe to be more appropriate), this would indicate a shortage of more than 100 SUD treatment beds for adults and another 30 to 40 beds for children/adolescents. Any additional beds would need to be designed to ensure that they reach the high-needs populations that are currently being missed.
3. Consider the comparative needs of children/adolescents and adults, as well as the comparative quality of underlying information for both. We found that bed shortages are considerably larger, in absolute terms, for adults compared with those for children/adolescents. However, in terms of standardized rates of need (i.e., need per 100,000 population), estimates are often comparable between age groups, which also suggests comparable shortages. We also note that the quality of available primary and secondary source information on bed need was much stronger for adults compared with that for children/adolescents; such consideration may factor into Sacramento County's decision about which investments to prioritize.