California Hospital Letter Association ​Response to ​​​​6-11-25 Stakeholder Meeting on APH Regulations

1. Some stakeholders provided comments recommending a 1:6 nurse-to-patient ratio for adult patients and a 1:4 nurse-to-patient ratio for pediatric/adolescent patients, what specific patient needs justify a different ratio based solely on age?

CHA concurs that different staffing requirements should be in place — and, in fact, are already in place in hospitals’ practice without these regulations — for psychiatric hospitals that treat children and adolescents. Again, the department needs to consider the fact that creating a safe and effective healing environment is about far more than requiring a particular ratio of only nurses to patients in care.​

Existing state and federal requirements, validated by empirical research, already reflect that acute psychiatric hospitals must use a team composed of a minimum number of not only nurses, but also licensed psychiatric technicians and mental health worker counselors.

In CHA’s comments during last month’s listening session, as well as in CHA’s letter to the department last month, CHA recommends a 1:5 ratio for child and adolescent patients. This team should be composed of 50% RNs or LVNs, and the team should include licensed psychiatric technicians and mental health worker counselors.

While youth take fewer medications and have fewer medical complications requiring nursing care than adults, young people do require more observation and supervision. The reasons for a more aggressive approach to staffing for children and adolescents are based primarily on their safety risks and developmental needs.

Children and adolescents admitted to inpatient psychiatric care are most commonly admitted for significant risk of harm to themselves. Today, suicide rates among youth and rates of anxiety and depression are at all-time highs. Even prior to COVID, the rate of suicide among youth increased by 57% between 2007 and 2018.[13] In more recent years, hospital emergency departments have seen a 51% increase in suspected suicide attempts among adolescent girls and a 4% increase for adolescent boys.[14]

Given that young people are still developing executive functioning skills and impulse control and are most frequently admitted for being at significant risk of harming themselves, the additional staffing is focused on more intensive observation and supervision. Again, observation and supervision tasks and responsibilities are most often carried out by psychiatric technicians and mental health worker counselors, rather than RNs.

2. Do APHs recruit nursing staff (RNs, LVNs, and PTs) with specific skills for working with pediatric/adolescent patients that differ from those working with adult patients? What additional training should nursing staff receive when working with pediatric/adolescent patients in the APH setting?

Yes. Treatment goals and approaches for young people are different, based on their development stage and accompanying skills. Since young people receiving inpatient psychiatric treatment are most commonly admitted because of the risk of harm they pose to themselves (i.e., suicide), their inpatient treatment and required staff skills and training must focus largely on safety and stability.

The recently published Handbook of Evidence-Based Inpatient Mental Health Programs for Children and Adolescents recommends:

While there will be some variation depending on specific roles and responsibilities assigned to staff at different organizations, orientation to the following is generally recommended: (1) child abuse reporting requirements, (2) behavior management strategies, (3) crisis prevention and de-escalation strategies, (4) milieu-based therapeutic programming, and (5) environmental safety.[15]​

Patient observation and therapy — not simply the nursing assessments and care provided by RNs, LVNs, and LPTs — are different for children and adolescents. For example, social workers play a critical and unique role with young patients because of their interactions with children’s caregivers and parents, as well as with other support systems. This could include the child’s school, regional centers for children with intellectual or developmental disabilities, probation agencies, or child protective services.

3. What data should an APH collect to validate their policies and procedures accurately and consistently determine appropriate staffing levels that meet patient needs?​

As described in CHA’s prior letter, determining staffing levels appropriate to meet patient needs is a continuous process that includes ongoing data collection. Existing state regulations require every acute psychiatric hospital to have a method for determining psychiatric nursing staffing requirements that is based on an assessment of patient needs.[16]​ In order to comply, assessments of patients’ needs are conducted in multiple ways and help determine how frequently each patient requires face-to-face observations (such as every 15 minutes, or more often) or whether additional staff should be utilized.

First, upon admission, each patient receives a thorough nursing assessment, which can include up to 20 different components — everything from risk of self-harm or aggression to medical concerns, as well as patient strengths, needs, and treatment goals. Each patient also receives a physical exam from a physician, a psychiatric evaluation from a psychiatrist, psychosocial and discharge planning assessments from social  work staff, and several other assessments that inform their treatment and discharge plan. Hospitals use common, evidence-based tools including the Columbia Suicide Severity Risk Scale, Assessing and Managing Suicide Risk (AMSR) tool, and the Broset Violence Checklist.

Additionally, each patient receives a face-to-face assessment from an RN to determine their acuity level several hours before the end of each eight- and/or 12-hour shift. Hospitals use an acuity staffing tool to assign numerical weights to a list of specific patient features or risks. Once each patient is assessed, a nursing supervisor reviews the report and determines any staffing adjustments that should be made to ensure the appropriate number and skill mix of staff who should be present for each shift.

Examples of “high acuity” patient features that could necessitate additional staff include:

• High risk of suicide
• Need for more assistance with self-care or feeding
• Starting of a new medication
• Multiple acute crises that needed to be de-escalated since the previous shift
  

Further, hospitals conduct patient observation (“rounding”) on every patient around-the-clock, which is carried out by primarily by MHWs either every five minutes or every 15 minutes, depending on the patient. Patient observation through rounding is the primary tool an acute psychiatric hospital uses to ensure patients are safe. These team members must immediately report any behavior changes they observe to nursing staff.​

By design, patients do not spend much time alone or in their rooms. During waking hours, a highly structured daily routine with therapeutic activities is one of the most important tools to treat patients. As a result, multiple types of staff observe patients throughout the day and identify any changes or risks that could necessitate additional observation or additional staff being brought onto a unit. Ultimately, nursing supervisors determine whether additional staff above baseline levels should be deployed to ensure safety and quality of care.

Additionally, the following data represent a non-exhaustive list of the information hospitals collect, review, and report to external regulatory agencies, all of which helps assess whether staffing is adequate to ensure patient safety and measure the quality of care provided:

• Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program: Reporting required by all inpatient psychiatric hospital providers licensed and paid under the federal Inpatient Psychiatric Facility Prospective Payment System. Measures include:
• ​Hospital-Based Inpatient Psychiatric Services (HBIPS)-1: Admission Screening for Violence Risk, Substance Use, Psychological Trauma History and Patient Strengths completed
• HBIPS-2: Hours of physical restraint use
• HBIPS-3: Hours of seclusion use
• HBIPS-5: Patients discharged on multiple antipsychotic medications with appropriate justification
  
• Alcohol Use/Alcohol and Other Drug Use Disorder/Tobacco Use Brief Intervention or Treatment Provided or Offered
• Screening for Metabolic Disorders​
• Influenza Immunization
• Follow-up after Hospitalization for Mental Illness, 7-Days and 30-Days​
• Transition Record with Specified Elements Received by Discharged Patient​
• Rate of Readmission After Discharge from Hospital
• Medication Continuation Following Inpatient Psychiatric Discharge
• Starting next year, the Centers for Medicare & Medicaid Services will require universal collection of patient satisfaction data from inpatient psychiatric hospitals as well, through a standardized Psychiatric Inpatient Experience (PIX) survey.[17] The elements of data to be collected were developed by experts at Yale University and validated by empirical research,[18] which found:
• ​Significant evidence that positive patient experience and improved health care outcomes are closely linked
• Patient experience measurement must be centered on the elements of care that matter most to patients, while also corresponding to the care process relevant to the health service (i.e., operationalizing concepts of dignity, recovery, and service-user experience)

The survey consists of 23 items in four domains (click here to view all items in the survey). Individual facilities can add supplemental items to the survey instrument, provided that they do not amend or remove the key elements of the PIX survey in order to collect data for and report on this measure. Domains include:

• Relationship with Treatment Team
• Nursing Presence
• Treatment Effectiveness
• Healing Environment
  

4. What barriers, if any, do you see with implementing specific nurse-to-patient ratios in APHs?

The existing nursing and behavioral health workforce shortage will present a significant barrier. Nearly one-third of Californians currently live in areas with a shortage of mental health care professionals. Over the next decade, the supply of psychiatrists, psychologists, and licensed clinical social workers is expected to continue to decrease, as many professionals retire from the workforce.[19]

Many hospitals report that retention and staff turnover have become more challenging in recent years. More than ever before, acute psychiatric hospitals are competing with new and different employment​ options as other sectors expand mental health care services. Since the COVID pandemic, nurses and mental health professionals are increasingly interested in working for schools, outpatient primary care clinics, travel nursing agencies, private practice, or telehealth — all of which offer more flexibility and work/life balance at the same or higher salaries as those offered by hospitals. RNs, especially with psychiatric training or experience, are particularly difficult to recruit and retain as many are now advancing into nurse practitioner careers that provide higher pay, more independence, and greater flexibility.

Some behavioral health workforce challenges are unique to psychiatric hospital settings, including patients on involuntary holds or conservatorships, facilities that are locked, and the ongoing need to balance patients’ rights with safety.

Based on the acuity and severity of the patient population in inpatient psychiatric hospital settings, some hospitals report that staff of all types can often choose a lower-stress role for approximately the same pay. Even mental health clinicians with master’s degrees often arrive without academic training or experience that exposed them to the intensity of inpatient behavioral health work. Increasing numbers of high-need, complex patients can contribute to patients having longer lengths of stay in the hospital than necessary as they await openings in hard-to-find community placements. This can be challenging and disheartening for staff. Some hospitals report seeing increases in adult patients with developmental disabilities and language needs that are a challenge to manage and require the provision of new and additional staff training.​

In addition to workforce challenges, inadequate reimbursement rates, especially for Medi-Cal covered patients, have not kept pace with the growing demand for higher salaries for employees. Hospitals must receive more adequate reimbursement if they are going to be required to increase the quantity or types of required minimum staff.

5. Do you have any other comments/suggestions regarding the APH staffing ratios that you would like the Department to consider?

While you are hearing from some stakeholders who claim that registered nurses must be held up as the only personnel type these regulations should consider, they are out of step with the longstanding position of their colleagues at the national level. As mentioned earlier, the American Psychiatric Nurses Association and American Nurses Association urge nurses nationally to champion safe and effective staffing overall — not just for their own profession.

Further, while California nurses’ unions want CDPH to establish registered nurse-only ratios, long-standing nursing staff regulations for psychiatric units within general acute care hospitals include LVNs and psychiatric technicians — not just RNs — in the 1:6 ratio.[20]​​

Additionally, psychiatric health facilities (PHFs), of which there are currently 34 licensed in California, care for a substantially similar population and offer substantially similar treatment, focus on a multidisciplinary team model.[21] Nearly every licensed PHF in California (31 of 34) is designated and approved to admit patients that are involuntarily detained under the Lanterman-Petris-Short (LPS) Act.[22] Patients receiving treatment in acute psychiatric hospitals or units have the same rights as those treated in PHFs.[23] Pursuant to federal parity requirements, Medi-Cal behavioral health plans have the same care authorization policies and procedures for acute psychiatric hospital services and PHFs.[24]

State regulations for PHF staffing require:[25]​

• An RN, who is employed 40 hours per week
• A clinical director, who shall be a licensed mental health professional and may also serve as the administrator
• A clinical psychologist or psychiatrist, designated by the clinical director, who shall review and approve interdisciplinary treatment plans
• A physician, who shall be on-call at all times for the provision of physical health care and those services which can only be provided by a physician​
  

Each facility must meet the following full-time equivalent staff to census ratio, in a 24-hour period:

[13] Curtin, S. C. (2020). State suicide rates among adolescents and young adults aged 10–24: United States, 2000–2018. In National vital statistics reports (Vol. 69, No. 11). National Center for Health Statistics.

[14] Yard, E., Radhakrishnan, L., Ballesteros, M. F., Sheppard, M., Gates, A., Stein, Z., Hartnett, K., Kite-Powell, A., Rodgers, L., Adjemian, J., Ehlman, D. C., Holland, K., Idaikkadar, N., Ivey-Stephenson, A., Martinez, P., Law, R., & Stone, D. M. (2021). Emergency department visits for suspected suicide attempts among persons aged 12–25 years before and during the COVID-19 pandemic — United States, January 2019–May 2021. Morbidity and Mortality Weekly Report, 70, 888–894.

[15] Leffler, Jarrod & Thompson, Alysha & Simmons, Shannon. (2024). Handbook of Evidence-Based Inpatient Mental Health Programs for Children and Adolescents. Issues in Clinical Psychology.

[16] California Code of Regulations (CCR) Title 22, Sec. 

[17] ​​YPX Insights Psychiatry Inpatient​ (PDF) 

[18] Klemanski DH, Barnes T, Bautista C, Tancreti C, Klink B, Dix E. Development and Validation of the Psychiatric Inpatient Experience (PIX) Survey: A Novel Measure of Patient Experience Quality Improvement​. Journal of Patient Experience. 2022;9.  

[19] 2021 California Behavioral Health Workforce Assessment​​ (PDF)​, Center for Applied Research Solutions, Prepared for Advocates for Human Potential and California Department of Health Care Services, April 2022.​​​

[20] Title 22, Sec. 70217(a)(13) 

[21] DHCS, Licensed Psychiatric Health Facilities​ (PDF) 

[22] DHCS, LPS Designated Facilities 

[23] Rights for Individuals In Mental Health Facilities Admitted Under the Lanterman-Petris-Short Act​ (PDF)​

[24] DHCS Behavioral Health Information Notice 22-017 (PDF) 

[25]​ Title 22, Sec. 77061​​