The state has been hiring county sheriffs to sit with mentally ill patients in hospital emergency departments because there are too few beds for people who need intensive psychiatric care.
In recent months even patients who have been court-ordered into state psychiatric care have had nowhere else to go but emergency rooms because they cannot by law be held in local jails and no inpatient beds at acute care facilities have been available.
Dr. Richard Marasa, an emergency medicine doctor at Springfield Hospital, described a recent incident in the ER in which a man, awaiting placement in a Level 1 psychiatric center, “exposed himself and was masturbating in clear view of another patient’s wife.”
Windham County Sheriff Keith Clark describes an emergency room scene where a psychiatric patient, hospitalized involuntarily and awaiting treatment, struck his deputy in the face with an uprooted IV pole.
These are examples of incidents that have occurred during the nearly 5,000 hours that Clark’s deputies have logged “watching” emergency room patients, who are held against their will for indefinite periods until an inpatient bed in a psychiatric treatment facility opens up. More often, Clark says, his deputies get along well with the patients, playing cards to keep them occupied and “building rapport.”
“Patient watches,” which have lasted as long as 16 days, typically involve two sheriffs at a time, sitting next to a patient for 24 hours a day to make sure they don’t hurt themselves, or others, or escape from the hospital.
“Essentially we are turning small little alcoves off of emergency rooms into jail cells,” Clark told a group of lawmakers recently.
Even though the state has spent roughly $1 million on patient watches, stories abound about emergency room visits gone awry, and both sheriffs and hospital repeat the same refrain — the wait times for psychiatric care put patients in a wholly inappropriate setting for far too long.
Last year, the Department of Mental Health spent more than $600,000 to pay for 10,181 hours of bedside supervision by sheriffs. The pace of requests, which come from the hospitals, has picked up this year, and the department has asked the Legislature to grant it another $950,000 to meet unanticipated demand. Less than four months into the current fiscal year, DMH paid out roughly $400,000.
“Patient watching” is a new phenomenon, borne of desperation. Since Tropical Storm Irene forced the closure of the Vermont State Hospital, the state has struggled to find a sufficient number of placements for severely mentally ill patients at community hospitals around the state.
The department is developing a regional system of care to replace the state hospital and now has 32 beds available at four facilities around the state. The Vermont Psychiatric Care Hospital in Berlin that would serve 25 patients is set to open in August.
In the meantime, sheriffs and medical personnel are struggling to protect patients and public safety in local hospitals. Lawmakers and some physicians on the front lines question whether the state’s plan to fragment the system of care into regional hubs (as opposed to rebuilding another 54-bed facility to replace the Vermont State Hospital) will solve the problem. They worry that “patient watching” will continue after the Berlin hospital opens.
Dr. Marasa is one of several hospital medical directors who articulated their frustrations last week in an email string that was eventually forwarded to Gov. Peter Shumlin. In his appeal to the governor, Dr. Marasa wrote, “All our efforts to date have not made anything better and your current plan is doomed for failure. I can only hope and pray that with this knowledge you will promptly take the steps necessary to give proper inpatient care to Psychiatric patients instead of leaving them in Emergency Departments where they cannot get proper care and they impose an ominous threat and sometimes create serious harm to health care workers and our community.”
Sheriff Clark is disenchanted with the situation for a number of reasons.
Patient watches draw his deputies away from their other duties and saddles them with an undue emotional burden, according to the sheriff.
“When they are dealing with someone who says, I’m going to kill myself if I leave here, and ultimately does, that takes a toll.”
Clark described one assignment at Brattleboro Memorial Hospital, during which his deputies were called on, in three separate occasions, to watch over a woman who, each time, voiced suicidal intentions.
“The young lady kept saying she if was released she was going to kill herself,” Clark said. “She was going to overdose. Three times we saw her in the emergency room. The fourth time, we didn’t see her. She was successful. And my deputies took that hard.”
Hospital representatives have complained that federal regulations can make bona fide security hard to come by.
Sheriffs are there to provide security — to the patient and to the hospital staff — but a Catch-22 can constrain their ability to actually offer that service. If the patient hasn’t committed a crime, they don’t fall under policy custody, and if they aren’t under their custody, Centers for Medicaid and Medicare rules prohibit sheriffs from physically intervening to restrain them during a violent episode.
Springfield Hospital ran afoul of that rule last May during an incident documented by CMS and published on the Division of Licensing and Protection website. “Patient #19” was brought to the hospital involuntarily to await placement in an acute care facility. An altercation ensued when a nurse attempted to administer medication and it ended — according to the nurse’s documentation — with the patient “grabbing at my waist attempted to hit my back as I was exiting the room and followed me out of the room.”
As the patient proceeded to “curse and swing at all people around [him/her]” and kick and bite at the staff, the sheriffs stepped in, handcuffing the patient and putting on leg cuffs and a spit hood. CMS reported that there was no evidence the patient had been in police custody, and the nurse expressed confusion about the care requirements for involuntary status patients.
Clark said his deputies are often confused about the rules constraining their behavior during their emergency room stints.
“The deputies constantly call me and say, ‘Sir, I’ve got the hospital telling me one thing, the Department of Mental Health telling me another, and your policies are in conflict with those two.”
The Windham sheriff said he’s also noticed another trend taking root — a growing predisposition to press criminal charges for patients with psychiatric illnesses, which is fueled by tense emergency room episodes.
“What we are seeing now is that crisis workers, because there is a lack of bed space and it is far safer to have people in jail cells, have taken steps to try to have people charged,” Clark told lawmakers.
He described an incident in the Springfield emergency room in which a patient “because of his illness, tried to grab one of my deputy’s firearms.”
“My deputy quickly had him secured and it started to de-escalate,” Clark explained, but by then a nurse had called a crisis worker and reported the event as a crime. “My guy said I’m not doing that because this person didn’t try to take my weapon because of criminal intent. He was just trying to get out of the emergency room.”
On the flip side, hospital staff have expressed indignation when a patient’s criminal charges are dropped and they are sent from a correctional facility to a hospital where employees are ill-equipped to handle them. The patient who masturbated in the Springfield ER had had his criminal charges dropped, which, Marasa noted, meant that “we are not allowed to seclude or restrict most of his activities.”
From chauffeurs to watchers
The link between law enforcement and patients with psychiatric illnesses predates Irene. Police have traditionally been contracted by the state to transport involuntary status patients to and from psychiatric facilities, a service they continue to provide.
But post-Irene, the Department of Mental Health has paid police to go beyond their chauffeuring role, supervising involuntary status patients during often lengthy emergency room stays.
For most county sheriffs, the reimbursement rate is $35 per hour, but in 2012, the department set up special arrangements with two departments — Lamoille County and Windham County — to ensure that a reliable supply of sheriffs would be on hand to provide “patient watches” in both the northern and southern halves of the state. Clark says the reimbursement rate adequately covers the cost to his department.
Paul Dupre, who became commissioner of the department in July, said the practice predates his tenure. Deputies receive at least a six-hour training to equip them for the job, according to DMH officials.
“We wanted to make sure we had a cadre of folks available who we knew were trained the way we wanted them to be trained and who had the same attitude about it as we did,” Dupre explained.
DMH settled on a rate of $70 per hour for transports and patient watches conducted outside the sheriff’s county borders. (If there are two deputies assigned to a patient watch, the rate drops to $55 per hour for the second person.)
The contracts also permit limited reimbursements for “start up costs,” travel expenses, and vehicle maintenance. The rules specify that when restraints are necessary, “soft/nylon” ones should be the default rather than metal shackles, but sheriffs can make exceptions on a “case by case basis.”
The original contract with Lamoille, which was approved by the Agency of Administration, took effect in September 2012 for one fiscal year. It was subsequently amended by department three times and extended through June 30, 2014.
The maximum billable amount was also increased from $63,000 eventually to $450,000. According to DMH records, between September 1, 2012, and November 18, 2013, Lamoille has provided 7,116 hours at a total cost to the state of $492,264.
The Windham contract took effect May 15, although Clark said his department first started providing patient watches in December 2011.
Other sheriff departments continue to provide transports and patient watches, some of them on a regular basis. Orange County, for instance, provided more than 1,000 hours in fiscal year 2012, receiving $60,000 in compensation. Addison County officers provided 333 hours during the same time period.
The arrangement works like this: When hospitals receive a patient on involuntary status whom they deem a risk to themselves or staff, they call DMH to request a sheriff. The Green Mountain Psychiatric Care Facility in Morrisville fields the phone calls, which can come at any hour, because they have a 24/7 answering service.
According to Dupre, if there’s an “unusual situation” — in which, for instance, a child needs to be restrained with hard rather than soft shackles — he or another senior department official will vet the request. Otherwise, the department authorizes the request, and the sheriff dispatches one or two deputies to watch over the patient indefinitely, on the state’s dime.
Lamoille County Sheriff Roger Marcoux said he expanded his department significantly after signing the contract with DMH: “We are already over 40 people and when we started this we were 25 people.”
“I have gone out and recruited people — municipal police, retired police chiefs. These folks have all maintained their law enforcement certification,” he said, explaining that, “You have to have the right personality to do this. You have to be patient, and you have to be a people person. If you are short-fused, it’s not going to work.”
The department has also used money from the Department of Mental Health contract to purchase two unmarked Toyota vans and outfits for its officers. The contract specifies that, whenever possible, police should show up in plain clothes. The uniform can be counterproductive when trying to comfort a patient, Marcoux explained.
Patient watching in practice
Hospitals say they depend on the service. “I don’t know how we would have managed some of the patients without them,” Janet Sherer, chief of patient care services at Springfield Hospital, said.
“It’s not a new relationship, but it’s certainly a stepped up one,” said Kathleen McGraw, chief medical officer at Brattleboro Memorial Hospital.
Marcoux and Clark both say their deputies have become adept at “de-escalating” situations without using restraints.
Stopgap solution or permanent policy?
The Shumlin administration continues to make assurances that once the decentralized system is fully operational, it will successfully divert people from crises and reduce pressure on acute care facilities.
But lawmakers, hospital staff, and other stakeholders aren’t so sure that acute care needs will wane. And even if they do, some lawmakers worry that by then, it will be too late to dismantle certain features of the system — such as patient watches — that were put in place as part of the post-Irene triage.
“I think there are just more patients,” McGraw said. “When they have these beds online, I’m not sure the number [of beds] is really going to sufficiently manage the number of patients out there at this point. I think this is a longer-term problem we need to look at.”
Lawmakers on the House Appropriations Committee, who are in the midst of mulling the nearly $1 million additional budget request, asked Dupre for assurance that the practice would come to an end once the new 25-bed Vermont Psychiatric Care Hospital is up and running.
Rep. Martha Heath, D-Westford, chair of House Appropriations, told the commissioner, “I think we’ve established an expectation that has potential to continue to be an expectation after the situation changes and obviously it’s very concerning to us.”
Dupre responded that he did view the policy as an “in between” measure. Still not assuaged, the committee requested that Dupre inform hospitals that he plans to discontinue the practice next summer.
In an interview, Dupre said he thinks the cost of the sheriffs’ service is justified.
“They’ve been available at all kinds of ungodly hours to transport and to be with people,” Dupre said. “They have in some cases reduced the cost some to try to make it more reasonable. but I think overall we would be spending a lot of this money somewhere else. We don’t have all the [acute care] beds now, so we’re not spending the money on those beds so we’re spending it on this other care.”
But to Clark — a recipient of a large portion of that money — the situation is untenable. He’s worried about his deputies, but he says he’s more concerned about the patients they are watching over. Referring to the total number of bedside hours his department has racked up, he told lawmakers, “That’s 4,900 hours that someone could be getting treatment.”