Transportation of mental health patients : sheriffs' offices continue to transport mental health patients; however, number of transports has decreased

Follow-Up Review 12-18

June 2012

Georgia Department of Audits and Accounts
Performance Audit Division
Russell Hinton, State Auditor Leslie McGuire, Director

Why we did this review
This follow-up review was conducted to determine the extent to which the transportation of mental health patients, and the challenges sheriffs face in making these transports, has changed since our November 2009 Special Examination (#10-01).
The purpose of the November 2009 examination was to characterize the nature of mental health transports and the impact on local sheriffs' offices. The report examined patient load, transportation costs and suggested several mitigation strategies that, if implemented, could reduce the overall burden associated with such transports.
Who we are
The Performance Audit Division was established in 1971 to conduct indepth reviews of state programs. The purpose of our reviews is to determine if programs are meeting their goals and objectives; provide measurements of program results and effectiveness; identify other means of meeting goals; evaluate the efficiency of resource allocation; assess compliance with laws and regulations; and provide credible management information to decision-makers.
Website: www.audits.ga.gov Phone: 404-657-5220 Fax: 404-656-7535

Follow-Up Review - Transportation of Mental Health Patients
Sheriffs' offices continue to transport mental health patients; however, number of transports has decreased
What we found
Since our 2009 report, the Department of Behavioral Health and Developmental Disabilities (DBHDD) convened a work group to address issues with transporting mental health patients. The work group included representatives from the Georgia Sheriffs' Association (GSA), other law enforcement personnel, and mental health providers. As discussed in the remainder of this review, some of the problems sheriffs faced when transporting mental health patients have been addressed by changes DBHDD made as a result of this work group. Overall, the number of transports to state psychiatric hospitals has decreased since 2009 and, according to DBHDD staff, more mental health needs are being met with community-based services. Our 2009 report addressed the following issues that presented challenges for sheriffs transporting patients: hospital closures, Emergency Receiving Facilities (ERF) availability and usage, and medical clearance requirements. The report also addressed strategies other states used to transport similar patients. This follow-up report provides information on DBHDD's activities and the resulting changes in the sheriffs' transportation of mental health patients.
As reported in 2009, the responsibility for transporting involuntary and court-ordered mental health patients rests with Georgia's county sheriffs. Based on available data, the total number of transports made by sheriffs to state psychiatric hospitals has decreased over the period from 16,162 in fiscal year 2009, to 12,396 in fiscal year 2011 (see Exhibit 1).

Requested Information on Transportation of Mental Health Patients Follow-up Review

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Exhibit 1: State Psychiatric Hospital Encounters Likely Transported by a Sheriff1

Legal Status

FY 2009 Number Percentage

FY 2011 Number Percentage

Difference

Involuntary Civil Commitment 14,841 92%

11,359 92%

-3,482

Hold Orders

765

5%

507

4%

-258

Forensic Commitment

556

3%

530

4%

-26

Total

16,162

12,396

-3,766

1 In 2009, these patients accounted for approximately 85% of all mental health encounters at state hospitals. The remaining 15% were voluntary civil or of an unknown type, and, according to DBHDD, likely not transported by a sheriff. Source: DBHDD State Hospital Encounter Data

Hospital Closures and Community Services

According to DBHDD staff, the mental health service provision model has shifted from centralized stateoperated facilities to a community-based approach. Under the new model, the state certifies Crisis Stabilization Units (CSUs), and designates private psychiatric and acute care hospitals, to provide services to patients that previously would have been served in state psychiatric hospitals. State-level data describing individuals served by community-based ERFs does not include, or approximate, the method of transport. As a result, a comprehensive assessment of the sheriffs' transportation responsibilities is not quantifiable.

Since 2009, the state closed Northwest Georgia Regional Hospital in Rome and eliminated adult mental health services at Central State Hospital in Milledgeville.1 The state also discontinued Crisis Stabilization Programs operating in three of the remaining state hospitals. In fiscal year 2009, these stateoperated facilities accounted for 6,137 of the 16,162 mental health transports made by sheriffs. To offset this reduction in capacity, DBHDD designated or initiated contracts with additional ERFs including two Crisis Stabilization Units and two acute care hospitals and one private psychiatric hospital.2 During the same period, facilities dropped the ERF designation. As a result of all changes, the state has experienced a net increase of two ERFs available for mental health patients. Additionally, CSUs served 1,042 additional admissions in fiscal year 2011 as compared to fiscal year 2009 and are on pace to admit an additional 1,809 in fiscal year 2012 (see Exhibit 2). The increase in the number of patients served by CSUs and private psychiatric and acute care hospitals (data unavailable) may account for the decrease in mental health patients served by state psychiatric hospitals. DBHDD staff also note that communitybased services have prevented the need for treatment services provided by the state hospitals.

Exhibit 2: Crisis Stabilization Unit Admission Data

(FY 2009-FY 2012)

Fiscal Year

Admissions

Average Admissions Per Day

FY09

13,461

37

FY10

14,085

39

FY11

14,503

40

FY12.Q1-Q2

8,156

44

Source: DBHDD CSU Admission Data

Our review did find that, while DBHDD is increasing usage of community-based ERFs, the changes at Central State Hospital and the closure of Northwest Regional State Hospital have resulted in transportation challenges for sheriffs in those areas. These points are discussed on the following page.

1 Central State Hospital still receives forensic patients, but no longer services involuntary civil mental health episodes. In fiscal year 2011, CSH serviced 91 total forensic episodes. 2 In addition, a portion of the state-operated CSP beds were transitioned to inpatient beds at those hospitals.

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Most of the new ERFs and CSUs are located in close proximity to areas previously served by Northwest Georgia Regional Hospital in Rome (see Appendix A for a map of all facilities in Georgia). During the first six months of fiscal year 2012, these facilities admitted 957 involuntary civil patients.3 Comparing the first six months of each fiscal year, sheriffs transported 251 individuals to state hospitals in fiscal year 2012 and 985 transports in fiscal year 2009. In addition, sheriffs in these counties saw an increase in the average miles per transport from 111 miles in fiscal year 2009 to 197 miles in fiscal year 2012. As a result, sheriffs in the region made 75% fewer transports to a state hospital while still traveling 45% of the fiscal year 2009 miles. It is estimated that these transports resulted in an average 1,770 transport miles per county within the first six months of fiscal year 2012.4 During this same time period in fiscal year 2009, 985 state hospital transports originated in these same counties equaling an average of 3,643 miles per county.
When Central State Hospital closed its Adult Mental Health wing, the counties in its former catchment area were divided between East Central Regional Hospital in Augusta, West Central Georgia Regional Hospital in Columbus, and Georgia Regional Hospital-Savannah. Sheriffs in these counties now drive an average of 132 additional miles per trip when transporting to a state hospital. In fiscal year 2011, sheriffs transported patients an average of 5,852 more miles per county compared to the previous catchment assignments. Even though sheriffs in these counties made about 55 fewer transports on average to a state hospital in fiscal year 2011, the distance traveled increased by an average of 1,208 miles per county. In addition, these counties saw an increase in average miles per transport from 80 miles in fiscal year 2009 to 215 miles in fiscal year 2011 (an increase of 268%).
State hospitals experienced 48 diversion days during fiscal year 2009. In fiscal year 2011, state hospitals experienced 53 diversion days and the first half of fiscal year 2012 saw 22 diversion days. It should be noted that the state hospitals have not been on diversion since October 2011. According to DBHDD staff, three of the five state hospitals contract with "overflow" hospitals and provide transportation to the overflow facility when the hospital reaches capacity.5 This process reduces the need for sheriffs to deliver an individual to a state hospital outside the assigned catchment area. Based on the fiscal year 2011 state hospital encounter data, approximately 97% of encounters originated within the appropriate catchment area.
The 2009 report indicated that sheriffs transported most patients to a state hospital, but suggested that DBHDD explore efforts to raise awareness of alternative community-based ERF options. During the workgroup sessions, the Georgia Sheriffs' Association (GSA) requested maps detailing the mental health facilities and services in each county. State law requires the transport of mental health patients to "the nearest available ERF." According to GSA, while the responsibility to advocate for a specific ERF should not rest with the sheriffs' deputies, the knowledge of alternative facilities may allow them to better advocate for their own resource usage. DBHDD indicated that the asset maps would be available in June 2012 with an accompanying education program directed at law enforcement shortly thereafter. Currently, DBHDD does not have an implementation plan to target clinicians for a similar training.
Changes to Forms and Procedures
Effective March 31, 2012, DBHDD redesigned the Form 10136 (see Appendix B) and now requires the referring clinician to contact the ERF staff to ensure space is available for a potential patient. The
3 The state contracts with these facilities on a per-bed basis. 4 Forensic patients accounted for 35 (14%) of these 251 transports. 5 According to staff, the remaining two hospitals do not require overflow services and therefore, have not established contracts. 6 This Certificate is used by clinicians when referring an individual for an involuntary mental health evaluation and authorizes transport to an ERF.

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process should reduce the potential for a sheriff to arrive with a patient and find that the facility does not have capacity to accept the patient. DBHDD stated it is interested in training and certifying clinicians in the proper use of the 1013 form, but has not developed or implemented a program as of the release of this report.
At the time of the original report's publication, DBHDD policy required appropriate medical screening of individuals prior to the person being transported to the State Hospital.... DBHDD's new policy states that if the individual has signs or symptoms of a medical condition that would warrant urgent medical intervention prior to transport the patient should not be transported. However, if the patient does not exhibit such signs, he or she may be transported, effectively eliminating the requirement that sheriffs make an additional transport for "medical clearance" prior to transporting a patient. Additionally, if a patient arrives at a facility and presents with a medical condition the facility cannot manage, DBHDD now requires the state hospital or CSU to transport the patient to the medical hospital.
Alternative Transportation Options
The 2009 report also addressed the use of alternative transportation options as a possible strategy to reduce the transportation burden placed on sheriffs. While most counties still rely on the local sheriff to manage transports for mental health patients, auditors identified two counties that had contracted with a private company to provide transportation for involuntary mental health patients. Athens-Clarke County and Oconee County contract with a fee-per-use transport provider. When the sheriff's office determines the patient poses no public safety risk, the private provider handles the transport. In Oconee County, the sheriff takes the individual into custody, and, if appropriate, arranges for the private provider to pick up and transport the individual to the assigned ERF. While a deputy does not perform the transport, the Sheriff's office still assumes responsibility for the safe transfer to the receiving facility. DBHDD also noted that there is a private vendor operating in Gwinnett County.
These arrangements reflect an interpretation of state law allowing county governing authorities to arrange for the transportation of mental health patients. DBHDD's redesign of the Form 1013 supports the use of an alternative transport provider, be it a private company, ambulatory service, or family member. In the original report, we interpreted the law to state that a sheriff is the only peace officer with the jurisdiction to perform the initial transport of an involuntary mental health patient across county lines to an ERF. However, no court has made a definitive determination.
Wait Time
In the 2009 report, GSA reported sheriffs had to wait extended amounts of time once they had delivered an individual to a state hospital. A review of the state hospital transportation logs showed that the wait was less than one hour 95% of the time in fiscal year 2009. We reviewed a sample of state hospital log data for fiscal year 2011 and it showed wait times of more than one hour occurred in less than 2% of the cases reviewed. In addition, GSA noted that its members had also reported a reduction in the wait times.
In its response, DBHDD indicated that it concurred with the conditions and evaluations identified in the report. It noted that the department will continue to explore opportunities for working with external partners to create and manage transportation practices which serve the needs of individuals in the most effective manner possible. In its response, the Georgia Sheriffs' Association indicated that it did not have any disagreements with the report.
A copy of the 2009 special examination report may be accessed at http://www.audits.ga.gov/rsaAudits.

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Appendix A: Emergency Receiving Facilities & State Hospital Catchment Areas

Dade

Catoosa Walker

Whitfield Murray

Chattooga

Gordon

Floyd

Bartow

Fannin Gilmer
Pickens Cherokee

Union
Lumpkin Dawson Forsyth

Towns

Rabun

Habersham

White

Stephens

Franklin

Hall

Banks

Jackson

Madison

Hart Elbert

State Operated Psychiatric Hospital Crisis Stabilization Unit (CSU) Private Psychiatric Hospital; Acute Care Hospital
New Facility
Discontinued Facility

Polk Haralson
Carroll
Heard

Paulding Douglas
Coweta

Cobb

Gwinnett Dekalb

Barrow Walton

Clarke Oconee

Oglethorpe

Wilkes

Lincoln

Facility in New Location

Rockdale

Fulton

Clayton

Fayette

Henry

Spalding

Newton

Morgan

Greene

Taliaferro

McDuffie

Butts

Jasper

Putnam

Hancock

Warren Glascock

Columbia Richmond

Troup

Meriwether

Pike Lamar Monroe

Jones

Baldwin

Washington

Jefferson

Burke

Harris

Upson Talbot

Crawford

Bibb

Wilkinson Twiggs

Johnson

Jenkins

Screven

Taylor

Peach

Emanuel

Muscogee Chattahoochee Marion

Macon

Houston

Bleckley

Laurens

Treutlen

Candler

Bulloch

Effingham

Schley

Stewart

Webster

Sumter

Quitman

Randolph

Terrell

Lee

Clay

Calhoun

Dougherty

Montgomery

Dooly

Pulaski

Dodge

Wheeler

Toombs

Evans

Crisp

Wilcox

Telfair

Tattnall

Turner
Worth Tift

Ben Hill Irwin

Jeff Davis

Appling

Coffee

Bacon

Long Wayne

Bryan Liberty
McIntosh

Chatham

Early

Baker

Miller

Mitchell

Colquitt

Berrien Cook

Atkinson

Pierce

Ware

Brantley

Glynn

Seminole

Decatur

Grady

Thomas

Brooks

Lanier

Clinch

Lowndes

Echols

Charlton

Camden

Catchment areas reflected here represent civil mental health episodes, catchment areas for forensic patients are different. Source: Department of Behavioral Health and Developmental Disabilities

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Appendix B: Form 1013 Certificate Authorizing Transport to ERF

For additional information or for copies of this report call 404-657-5220 or see our website: http://www.audits.ga.gov/rsaAudits