Over the past five years, Nevada's primary state psychiatric
hospital has put hundreds of mentally ill patients on Greyhound buses
and sent them to cities and towns across America.
Since July 2008, Rawson-Neal Psychiatric Hospital in
Las Vegas has transported more than 1,500 patients to other cities via
Greyhound bus,
sending at least one person to every state in the continental United
States, according to a Bee review of bus receipts kept by Nevada's
mental health division.
About a third of those patients were dispatched to California, including more than 200 to
Los Angeles County, about 70 to
San Diego County and 19 to the city of Sacramento.
In recent years, as Nevada has slashed funding for
mental health
services, the number of mentally ill patients being bused out of
southern Nevada has steadily risen, growing 66 percent from 2009 to
2012. During that same period, the hospital has dispersed those patients
to an ever-increasing number of states.
By last year, Rawson-Neal
bused out patients at a pace of well over one per day, shipping nearly
400 patients to a total of 176 cities and 45 states across the nation.
Nevada's
approach to dispatching mentally ill patients has come under scrutiny
since one of its clients turned up suicidal and confused at a Sacramento
homeless services complex. James Flavy Coy Brown, who is 48 and suffers
from a variety of
mood disorders including schizophrenia, was discharged in February from Rawson-Neal to a
Greyhound bus for Sacramento, a place he had never visited and where he knew no one.
The hospital sent him on the 15-hour
bus ride
without making arrangements for his treatment or housing in California;
he arrived in Sacramento out of medication and without identification
or access to his
Social Security payments.
He wound up in the UC Davis Medical Center's emergency room, where he
lingered for three days until social workers were able to find him
temporary housing.
Nevada
mental health
officials have acknowledged making mistakes in Brown's case, but have
made no apologies for their policy of busing patients out of state. Las
Vegas is an international destination and patients who become ill while
in the city have a right to return home if they desire, the state's
health officer, Dr. Tracey Green, told Nevada lawmakers during a hearing
last month.
She and others insist that the vast majority of
patients they are discharging to the Main Street bus station are
mentally stable and have family members,
treatment programs or both waiting for them at the end of their rides.
That was not true in Brown's case. His papers from Southern Nevada Adult
Mental Health Services read: "Discharge to
Greyhound bus
station by taxi with 3 day supply of medication" and provided a vague
suggestion for further treatment: "Follow up with medical doctor in
California." Brown said staff at Rawson-Neal advised him to call 911
when he arrived in Sacramento.
Nevada Health and Human Services
Director Michael Willden told lawmakers last month that while health
officials "blew it" in their handling of Brown, an internal
investigation found no pattern of misconduct.
But an investigation
by the Nevada State Health Division documented several other instances
from a small sampling of cases in February in which the state hospital
violated written rules for safely discharging mentally ill patients.
Other apparent violations surfaced during The Bee's investigation.
At least two patients from the Nevada system arrived in
San Francisco during the past year "without a plan, without a relative," said Jo Robinson, director of that city's Behavioral
Health Services department.
"We're
fine with taking people if they call and we make arrangements and make
sure that everything is OK for the individual," Robinson said. "But a
bus ticket with no contact, no clinic receptor, anything, it's really
not appropriate."
Robinson said she viewed the practice as
"patient dumping," and has reported it to federal authorities. "It's
offensive to me that they would show this lack of care for a client,"
she said.
Practice called risky
Nevada
mental health
officials did not respond to repeated requests for phone interviews for
this story, nor would they address a list of emailed questions about
the origins of the busing policy and the safety protocols in place.Southern Nevada Adult
Mental Health
Services, the agency that oversees Rawson-Neal, maintains detailed
written policies for transporting patients "to their home communities,"
with the stated goal of providing more appropriate care by the most
economical means possible.
The policy includes a special section
on "Travel Nourishment Protocol," specifying the number of bottles of
Ensure nutritional supplement the patient should receive for the bus
trip – essentially six per day.
Staff members are supposed to fill
out a "Client Transportation Request" form, which includes questions
about whether the patient is willing to go, whether housing or shelter
has been verified, and the cost of the trip.
The written policy
calls for staff to confirm that a patient has housing or shelter
available "and a support system to meet client at destination." They are
to provide information about "
mental health services available in the home community."
Interviews
with health officials in California and numerous other states indicate
Nevada's practices are unusual. None of the 10 state
mental health
agencies contacted by The Bee said that placing a psychiatric patient
on a bus without support would be permissible. And none recalled being
contacted by Rawson-Neal to make arrangements for a patient coming from
Nevada.
In California, where most public
mental health
treatment is overseen at the county level, agencies contacted by The
Bee said they rarely bus patients and that Nevada's practices seem out
of step with the standard of care.
Several described the practice as risky, even if patients have someone waiting for them at the end of their journeys.
"Putting someone whose
mental illness
makes them unable to care for themselves alone on a bus for a long
period of time could be absolutely disastrous," said Dorian Kittrell,
executive director of the
Sacramento County Mental Health Treatment Center.
Patients
could suffer relapses during their trips and potentially harm
themselves or other people, said Kittrell and others. They could become
lost to the streets or commit crimes that land them in jail.
"The risk is just too great," said Dr. Marye Thomas, chief of behavioral health for
Alameda County.
Southern Nevada Adult
Mental Health Services has had an ongoing contract with Greyhound since July 2009, said bus company spokesman Timothy Stokes.
Stokes
said he was unaware of any serious incidents involving mentally ill
patients from Nevada. He said Greyhound has contracts with "a number" of
hospitals around the country, but declined to identify them.
"We
take it on good faith that the organization is going to make certain
that patients are not a risk to themselves or others," he said.
Still, officials in several of California's largest counties said they rarely, if ever, bus patients out of state.
"We
don't do it, we never will do it, and we haven't done it in recent
memory, meaning at least 20 years," said David Wert, public information
officer for
San Bernardino County. Rawson-Neal has bused more than 40 patients to that county since July 2008.
Los Angeles County
officials said they have not bused a single patient out of state during
the past year, and when they have done so in the past they have
supplied chaperones. In the past five years, L.A. County has received
213 people from the Nevada hospital, according to The Bee's review, more
than any place in the country.
Likewise, in
Riverside County,
sending patients out of state "happens very infrequently upon request
of the family," said Jerry Wengerd, head of the county's Department of
Mental Health. "A staff member accompanies the client and it is usually by air." Nevada bused 20 patients to Riverside in the period reviewed.
Sacramento County
bought bus tickets for five patients during the past year, Kittrell
said. In all cases, he said, facility staff confirmed before patients
departed that a family member or friend would meet them at their
destinations, and provided referrals for treatment.
Organizations that advocate for mentally ill people said Nevada's busing numbers seem unjustifiably high.
DJ Jaffe, executive director of
Mental Illness
Policy Org., a nonprofit think tank, said his group often hears
anecdotally about patients being "dumped" from one county to another.
"Discharging
severely mentally ill patients inappropriately is policy in this
country," Jaffe said. "But getting rid of them altogether by busing them
out of state is, I think, rare. I am shocked by these figures. It seems
to be almost routine in Nevada."
After California, Arizona has received the most patients by bus from Nevada, at more than 100 over the five years.
But
Cory Nelson, acting deputy director for the Arizona Department of
Health, cautioned against drawing conclusions about Nevada's practices
based solely on number of bus tickets issued. In many cases, Nelson
said, relatives could have agreed to house patients or made treatment
arrangements before the clients left Las Vegas.
In rare cases,
Nelson said, a hospital can find itself in a Catch-22 situation when a
patient no longer needs to be in a hospital but refuses to cooperate
with a discharge plan. "It kind of leaves a hospital in a tough
situation," he said.
Still, the sheer number of patients bused from the Nevada hospital "does seem pretty high," he said.
Several people interviewed said the numbers might be explained in part by the unusual nature of Las Vegas."As
the whole country no doubt knows, Vegas is a pretty unique place," said
Dr. Lorin Scher, an emergency room psychiatrist with UC Davis Health
System.
The city's entertainment and casino culture draws people from all over the world, Scher noted, including the mentally ill.
"Many
bipolar patients impulsively fly across the country to Vegas during
their manic phases and go on gambling binges," he said. "Vegas probably
attracts more wandering schizophrenic people" who are attracted to the
warm weather, lights and action, he added.
"I am by no means
defending their practices," he said. "It certainly gives cause for
concern. But it's one possible explanation."
Stuart Ghertner, former director of Southern Nevada Adult Mental Health Services, cited other possible reasons.
He
said Rawson-Neal has been under siege for years because of state budget
cuts, a steady increase in poor people needing mental health services
in the Las Vegas area and a revolving door of administrators.
He noted the city had a disproportionate number of people displaced by the housing and mortgage meltdown of a few years ago.
"The
casino boom was over, people were losing their jobs and their homes.
They were stressed and they wound up in a mental health crisis,"
Ghertner said.
Between 2009 and 2012, Nevada slashed spending on
mental health services by 28 percent to address budget deficits,
according to data collected by the National Alliance on Mental Illness.
Even before those cuts, Nevada fell well below the national average in
spending on mental health services: In 2009, it spent $64 per capita on
such services compared with a national average of about $123, according
to the study.
"You're looking at a tsunami situation," said
Ghertner, a psychologist who resigned last year after five years as
agency director. "There is more pressure to turn patients over faster,
and fewer programs (in which) to place them. Perhaps busing them became
the easier solution."
It also is cheaper, he noted. Southern
Nevada Adult Mental Health Services spent a total of $205,000 putting
patients on Greyhound buses during the past five years, according to The
Bee analysis. The state hospital admits about 4,000 patients a year to
its inpatient unit, and inpatient care runs around $500 per day per
client, Ghertner said.
He said he was aware during his tenure that
Rawson-Neal was busing patients out of state but that he thought the
practice was rare.
At the time, "I had 800 employees and a $106
million budget," he said. Ghertner regularly reviewed numbers pertaining
to admissions, length of stay and other issues at the hospital, but
patient busing was never on his radar, he said.
"I'm embarrassed
to say that this practice was going on to this degree under my
leadership," he said. "I had no idea. It just never came up."
Ghertner
said the state mental hospital has been under stress since it opened in
2006, turning over five hospital directors since that time. That
instability has taken a toll, he said.
"This busing issue is a
symptom that reflects that the care there is not quality care," he said.
"Things clearly are being missed."
Willden, Nevada's Health and
Human Services director, said during last month's legislative hearing
that policies have been tightened and disciplinary actions taken to
ensure that patients are discharged only after the hospital confirms
care and treatment at their planned destinations. The hospital
administrator, Chelsea Szklany, now must approve all bus discharges
ordered by medical staff, he said.
"Southern Nevada Adult Mental
Health Services is committed to providing quality mental health services
to its patients," said spokeswoman Mary Woods in an emailed statement.
But investigations continue into the agency's practices.
Rawson-Neal
could lose vital federal funding pending an ongoing probe by the
federal Center for Medicare and Medicaid Services. California state
Senate President Pro Tem Darrell Steinberg has written a letter
expressing outrage to U.S. Secretary of Health and Human Services
Kathleen Sebelius.
The hospital's discharge practices also have
prompted a call for action by a member of the U.S. Commission on Civil
Rights. Commissioner David Kladney called for a broad investigation by
Nevada's governor and Legislature.
"As a Nevadan, I am ashamed
that my state is failing in its duty toward the neediest residents,"
Kladney said. Nevada, he said, appears to be "simply hoping that other
states will shoulder the responsibility."
Call The Bee's Cynthia Hubert, (916) 321-1082. Follow her on Twitter @cynthia_hubert. Bee researcher Pete Basofin contributed to this report.
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