County struggles with psych care cutbacks

Mary Leamy, left, board housing director for National Alliance on Mental Illness in Tuolumne County, and Elizabeth Soper, right, housing program director, talk with Edward Bailey, 74, of Sonora, who was diagnosed with Schizophrenia after the Vietnam War. Maggie Beck/Union Democrat, copyright 2012

Her family brought her to the ER because she was suffering from delusions and had made suicidal statements. Doctors determined the 65-year-old Jamestown woman  was a danger to herself and temporarily placed responsibility for her care in the hands of the county Department of Behavioral Health.

It was after midnight, and county crisis workers had difficulty reserving a bed for Chadwick at a crowded inpatient psychiatric ward in Modesto, the nearest hospital authorized to provide care for the uninsured mentally ill.    

She spent four hours in the Sonora ER and, for unknown reasons, decided to leave. She walked away against the advice of hospital staff and against the special legal status imposed on her by doctors who were concerned about her delicate mental state.    

Security cameras captured her walking across the hospital parking lot and onto Greenley Road wearing slippers, capri pants and a peach-colored T-shirt. It was the last time Chadwick was seen alive.    

Five weeks passed before a treasure hunter searching for old coins stumbled across her lifeless body propped against a large oak tree in a field less than a mile from the hospital.    

A federal investigation followed. County Behavioral Health and Sonora Regional changed some policies to improve safety for psychiatric patients, but law enforcement officials and mental health advocates say the endemic flaws that allowed a mentally fragile woman to vanish in the night six months ago remain unchanged.   

Emergency calls involving psychiatric patients who have fled from the ER are routine and have put the public at risk, according to Sonora Police Chief Mark Stinson. He said officers are called to the hospital roughly twice a week to look for patients who have absconded while being held for psychiatric treatment.    

“These types of calls have been pretty consistent for the past year and a half,” he said.    

In October, a Sonora man was struck by a car and injured while crossing Mono Way after he ran from the hospital to avoid being transported to a psychiatric care center outside of the county.    

With psych wards closing across the state and funding for county services increasingly scarce, emergency rooms have borne the brunt of recent health care policy changes. The combined result has torn a hole in the safety net that protects hundreds of Tuolumne County residents who maintain a tenuous grasp on mental health.

What was lost

 When Tuolumne General Hospital closed its doors in 2007 and the delivery of public health care became the exclusive realm of private medical providers like Sonora Regional, there was a major shift in the way the county cares for its mentally ill, according to Rita Austin of the Tuolumne County Department of Behavioral Health.    

Emergency rooms became the first stop for people deemed to pose a danger to themselves or others.    

While emergency medical services were absorbed by Sonora Regional Medical Center, the county’s only mental health care unit was scrapped in 2009 to be replaced by a series of contractual agreements with mental health facilities in other counties.    

Psychiatric patients are medically evaluated and tested for drugs and alcohol at Sonora Regional, then a Behavioral Health worker decides if the person should be transported to mental health hospitals in Modesto, Vallejo or Visalia, Austin said.    

It is a system that is being tried in several cash-strapped counties across California — including Tuolumne and Calaveras counties.    

County officials hoped to save more than $3 million a year by closing the county hospital, but local mental health advocates say the changes have come at a high cost for those in need.

An ongoing problem

Sgt. Jeff Wilson of the Tuolumne County Sheriff’s Office said deputies respond to about 10 cases a year that involve people running from the hospital after they have been legally ordered to undergo a mental evaluation.    

The most recent call, according to 911 records, was Monday, when a 19-year-old man walked away from the ER after waiting two days to be placed in a psychiatric hospital.    

“It happens enough to be a problem,” Wilson said.  

In each case, the patients are placed on an involuntary psychiatric hold know as “Section 5150” under the California Welfare and Institutions code.   

Under the health code, a person who poses a threat to himself or others, or is gravely disabled, can be detained for up to 72 hours. Doctors, mental health professionals and police have the power to detain a person on the basis of mental illness, but the procedure for declaring an individual 5150 varies from county to county.   

The provision strips people of many basic rights in the interest of protecting them from harming themselves or others. Austin said roughly 13 to 18 county residents per month require intervention based on psychological issues.  

“It’s a legal process of removal of rights based on a mental health condition,” she said.    

When the county abandoned the local psychiatric ward, it also lost the ability to use a special locked room in Tuolumne General Hospital. The simple exam room was located next to the nurse’s station and could be locked from the outside to prevent patients from running off, said Elizabeth Soper, a National Alliance on Mental Illness program director who also worked for the county Behavioral Health Crisis Team and was in charge of writing many 5150 orders.    

She believes the quality of care for the mentally ill has fallen sharply since the county hospital closed, and that both Sonora Regional and Behavioral Health shoulder responsibility for keeping patients safe under the new system.    

“The system of care is not working and both parties need to be held accountable,” Soper said.
  While the hospital is required to provide medical care to all patients, it does not have the legal ability to prevent them from leaving against their will, according to Sonora Regional Senior Vice President Julie Kline. Patients can be restrained only in extreme cases when they are acting violent. The old county hospital housed a designated psychiatric ward and had special rights to hold non-violent patients that primary care hospitals lack, she said.    

“They were a designated facility; we fall under a different umbrella of rules,” Kline said. “The whole process of seclusion and restraint that is part of psychiatric health is just not what we do.”
A patient’s perspective   

Vietnam War veteran Edward Bailey knows more about the county’s mental health safety net than most people.    

Wearing thick glasses and speaking with a gravelly voice, the 74-year-old Sonora resident suffers from schizophrenia, which causes him to hear voices. His illness has led him to be temporarily committed to psychiatric hospitals on a number of occasions, and he admits he has repeatedly tried to escape the ER while awaiting transportation.    

That was the case three weeks ago when Bailey stopped taking his medication. A social worker took him to the Sonora Regional emergency room so he could be placed on a psychiatric hold and compelled to take necessary antipsychotic drugs.    

“I didn’t want to take my pills, so they took me to the hospital,” he said.   

He said hospital staff gave him blood tests and then he was told to wait in an examination room until he could be transported to an out-of-county psych ward for treatment. After more than six hours, he said he got tired of waiting and tried to leave.    

“In my case, the nurses weren’t taking care of me so I just walked out,” he said.    

A security guard blocked his path and hospital staff eventually convinced him to stay. He was later placed in a Modesto psych ward for observation and so doctors could make sure he took his medication.    

He lives in an assisted living apartment building funded by NAMI and said he felt a lot more comfortable at the Tuolumne General psych ward. He said waiting for hours in the ER and traveling long distances takes its toll, and he misses the familiar county hospital staff.    

“They treated patients a lot better up there, they gave me the care I needed,” he said.    

Most patients who leave the emergency room do so simply out of frustration, according to Mary Leamy, housing director for the local NAMI chapter. She said the amount of time it takes for a person to be placed in a psychiatric facility has increased from just a few minutes at Tuolumne General to several hours at Sonora Regional.    

“Mental health patients are just like other people, they get tired of waiting around,” she said. “After three or four hours waiting, of course they walk out.”

Dollars and cents

The cost of mental health care is growing in counties across the state. California has cut $765 million from mental health care programs in the past two years, and funding has fallen 21 percent, according to NAMI.    

Austin said there simply aren’t enough people in need of a full-time psych ward in Tuolumne County to justify the huge expense.    

The county averages fewer than 200 psychiatric patients a year and state budget cutbacks have made it impossible for the county to afford its own inpatient psychiatric hospital.    

“Realistically, I do not see us ever having a locked facility opening in this county without a substantial increase in population,” she said.    

She said the current system, while flawed, is the only viable alternative. It has been complicated by a lack of available beds at most mental health hospitals in the state.    

Meanwhile, patients are left waiting in the ER under the care of hospital staff as social workers try to track down places for them to receive treatment, Kline said.    

“There are a limited number of facilities that will take these patients. That’s why it takes so long,” she said. “When the hunt begins to find a bed it can take hours and days.”    

Austin said the same problem is being experienced by small counties across the state as California lawmakers slash funding for programs designed to help the mentally ill.    

“I don’t feel that this is unique in any way to Tuolumne County,” she said.    

Neighboring Calaveras County uses a similar system by which the county contracts with Mark Twain St. Joseph’s hospital in San Andreas to provide emergency medical care, while mentally ill patients are assessed and transported elsewhere.   

That county typically has 8 to 15 patients per month who require involuntary psychiatric help, according to Brock Kolby, a psychiatrist with Calaveras County Behavioral Health Services.   

He agrees that Calaveras County has similar problems to those faced by Tuolumne County Behavioral Health and Sonora Regional, however, few if any 5150 patients totally abscond from the hospital. The main difference, he said, is how those patients are watched once they arrive in the ER.    

There is an interagency agreement among Behavioral Health, Mark Twain hospital and the Sheriff’s Office on handling unstable people.    

Kolby said it is standard procedure for Calaveras County sheriff’s deputies to stay at the hospital once they have dropped off a person who could pose a danger to himself or others. The deputy will not leave the ER until a Behavioral Health crisis worker takes over responsibility for the patient and determines if psychiatric help is needed. 

"The sheriff has the ability to bring people in, but Behavioral Health has the ultimate responsibility,” Kolby said.    

He said psych patients often try to leave the ER, but they generally don’t get very far because deputies remain at the hospital. None of these patents have walked away for more than a few hours before being returned.

Mending the safety net    

In the wake of Chadwick’s death, the Centers for Medicare and Medicaid Services conducted an investigation at Sonora Regional under the Emergency Medical Treatment and Labor Act in September. The agency found the hospital failed to meet four key requirements, according to CMS spokesman Jack Cheevers.    

The report, made public last week, said the hospital did not have proper signs posted and failed to keep records of medical assessments for some patients.   

Additionally, the hospital failed to show evidence they explained why 5150 patients were being transferred out of the county and did not keep records about where they were going.    

The hospital has until next month to take corrective action or face losing Medicare and Medicaid reimbursements, Cheevers said.    

The key to reducing risk to mentally ill patients who enter the ER is to coordinate efforts between the hospital, county Behavioral Health, the Sheriff’s Office and Sonora police, said Kline.   

“The biggest thing that we’ve done is that we’re talking more,” she said. “We recognized that we really had communication gaps.”    

She said the different groups now have regular meetings to discuss how best to care for mentally ill patients.    

The interim period between when a person has been medically examined by a physician and when they are transported to an out-of-county mental health facility is the main problem, according to Matt Peller, volunteer ombudsman with Catholic Charities in Sonora.   

“There are ways to make things safe and they’re choosing not to use them,” he said.   

Ideally, suicidal patients should be kept in a locked room away from any items with which to harm themselves, he said.    

Another alternative would be to outfit psychiatric patients admitted to the ER with special bracelets that can be tracked by GPS. That way authorities can more easily find them if they walk away.    

Kline said the hospital and Behavioral Health crisis workers use a variety of methods to keep psych patients from leaving that range from dressing them in hospital gowns, offering them food or having a security guard posted at the door.   

She said Sonora Regional is looking at outfitting unstable patients with medical bracelets, similar to those used for newborn babies, that will set off an alarm if they pass through the front door.    

Still, many mental health advocates say 5150 patients won’t be safe until a way can be found to confine them without using force or restraints on a hospital bed. Soper said more must still be done by Behavioral Health and Sonora Regional to ensure that another tragedy like the one that befell Chadwick does not happen again.   

“The point is that if you take somebody’s rights away, we as the county are obligated to provide adequate care,” she said. “Keeping people in the building is pretty basic.”