State hospitals seek $3.4 billion as department reports faster care for ‘incompetent to stand trial’ patients and positive results from enhanced treatment pilot

Stephanie Clendenin, director of the California Department of State Hospitals, told the Senate Budget Subcommittee No. 3 at a May hearing that the department’s 2025–26 Governor’s budget proposes a total budget of $3,400,000,000 and 38 new positions to maintain operations, deliver services and pursue capital outlay improvements.

Clendenin summarized the department’s system — five state hospitals, about 6,000 inpatient beds across acute, intermediate, skilled nursing and residential recovery levels, plus conditional‑release and community programs run with counties and private providers — and said the majority of commitments are forensic commitments from criminal courts or Board of Parole hearings. “The Department of State Hospitals manages the California State Hospital System and a continuum of treatment programs in communities and jails throughout the state,” she said.

Why it matters: The department treats the state’s most clinically complex patients, including those found incompetent to stand trial or not guilty by reason of insanity; changes to bed use, referrals and program activation timelines affect county partners, corrections, courts and patient outcomes statewide.

Caseload and IST updates

Brent Hauser, chief deputy director of operations, and other DSH executives described caseload changes and several program adjustments that appear in the budget request.

- DSH expects a patient census of about 8,527 by the end of 2025–26 — roughly 204 more patients than the current‑year projection. - A Metropolitan secure‑bed capacity project produced a one‑time savings of $4,400,000 while adding roughly 234 forensic beds across five units; three units are open and two units will open when a skilled nursing facility renovation completes. - DSH requested $21,700,000 ongoing to cover patient‑driven operating expenses and equipment tied to higher census and patient needs (utilities, pharmaceuticals, food, outside hospitalization).

Workforce and referrals

DSH described multiple workforce strategies: expanded psychiatric residency programs at Napa and Patton, fellowship partnerships with UCLA, UCSF, Riverside and Stanford, residency rotations with Kaiser and Community Memorial, outreach campaigns for hard‑to‑fill classifications and rapid hiring events. The department said it participates with CalHR in compensation discussions but is not the bargaining authority.

On referrals from the California Department of Corrections and Rehabilitation (CDCR) — the so‑called “Coleman” population — DSH described steps implemented in 2024 to increase referrals and utilization of DSH beds, including reviewing custody designations, a long‑term intermediate treatment program for difficult‑to‑reinstate incarcerated patients, and use of acute admission units for stabilization so patients can step down into unlocked dormitory settings at DSH. The department makes 336 beds available to CDCR for inpatient treatment and requested three position authorities to manage additional referral intake workload.

Vacancy and control‑section reductions

Clendenin said the proposed budget assumes vacancy‑reduction savings (control section 4.12) of 71.1 vacant positions for a $20,400,000 saving, and state operations reductions (control section 4.05) of $8,800,000, largely from Sacramento headquarters. DSH characterized most eliminated vacant positions as associated with closed patient units used for swing or renovation space or with long‑unfilled non‑care roles.

Enhanced Treatment Program (ETP) pilot: early outcomes

Kate Warburton, DSH statewide medical director, reported preliminary outcome data from the ETP pilot, a specialized unit for patients at highest risk of severe violence who cannot be safely treated in standard environments. The ETP pilot (an Atascadero 13‑bed unit and an additional 10‑bed Patton unit coming online in 2025) was created under AB 1340 and the department has asked for trailer‑bill language extending the pilot authorization through Jan. 1, 2030 to complete outcome analyses and implement Patton’s unit.

Warburton summarized early results: following ETP admission, “rates of aggressive incidence towards staff decreased by 71 percent, while aggressive acts towards other patients decreased by 94 percent. Serious injuries to staff decreased by 68 percent, and serious injuries to patients due to aggression by peers were altogether eliminated.” She also said some patients showed increased self‑injurious behavior after transfer into the ETP; referral screening was adjusted to better identify that risk and reduce restraint use. Of 16 unique patients discharged from the ETP, seven completed treatment and those seven showed sustained reductions in aggression (79 percent) and restraint use (87 percent) in the six months after discharge.

Court‑related compliance and savings

DSH reported large multiyear savings tied to timing changes for community‑based IST program activations (one‑time savings of $237.5 million in the current year, $82.1 million in 2025‑26 and $78.9 million in 2026‑27) because some activations will occur later than previously assumed. Department officials also said DSH has met the court’s Stiavelli compliance benchmark — initiating treatment for IST defendants substantially sooner than prior averages — and reported the February 2025 average time to initiating treatment for IST defendants was five days.

Questions from subcommittee members focused on staffing barriers, the interaction of new laws like SB 1323 (interest‑of‑justice option for IST proceedings) with referrals, the link between Prop 36 prosecutions and corrections referrals, and whether anticipated population changes at CDCR would affect DSH bed needs. DSH said it will monitor CDCR population projections and confer with partners.

Quotes

“The vacancy reductions pursuant to control section 4.12 includes a reduction of…71.1 vacant positions, resulting in savings of $20,400,000,” Stephanie Clendenin said, noting the positions were largely associated with closed patient units.

“Our preliminary data indicate this model is working,” Kate Warburton said of the ETP pilot. “Patients engage in significantly less aggression towards others after being admitted to the ETP compared to when they received care in our standard treatment environments.”

Ending note

DSH told the committee the 2025–26 budget proposal balances continuing operations, patient care expansion into community and jail settings, facility renewal and additional staffing authority tied to IST, Coleman and other caseload adjustments. Committee members asked for continued monitoring of utilization, staffing progress and interactions with ongoing court and legislative changes.