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September 16, 2014

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Mental Health:

Nevada buses hundreds of mentally ill patients to cities around the country

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Renee C. Byer / Sacramento Bee

James Flavy Coy Brown loves the leather couch where he often watches TV at the Home Sweet Home boarding house in Sacramento. He was released from a Nevada state psychiatric hospital in February, with only three days medication and a one way bus ticket to Sacramento, where he knew no one.

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.

Click to enlarge photo

James Flavy Coy Brown, 48, is addicted to smoking his pipe and consistently asks over and over for more tobacco as he waits for his morning medicine to be delivered. He now lives at the Home Sweet Home boarding house in Sacramento after a harrowing journey from a mental hospital in Las Vegas.

"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.

'A tsunami situation'

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.

"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."

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  1. I would like to also know how many people involved with this in the last 5 years also received bonuses.

  2. Meanwhile, Governor Sandoval has released the new State theme for bringing visitors with money to Nevada: "A world within. A state apart." A television ad for business development uses the tune "Don't Fence Me In", when it should be more like "Don't Fence Me Out, I'm broke".

    A standard Greyhound ticket from Las Vegas to Sacramento is only ~$92. Tourists should be reminded to sew a $100 bill into their pant legs to pay for an emergency bus fare to California, with a little left over to buy a greezy chili dog, a pack of chewy cheese crackers and a small bottle of water to accompany those long hours on the road to come.

    And if a passenger suddenly gets up, walks to the front of the bus and drags the driver out of his chair as you are approaching the higher altitudes at Donner Summit, don't worry, Greyhound is insured.

  3. The people responsible for this should be dropped off in a foriegn country with no money , no ID , and no where to stay and see how it feels to be lost, It would be about the same as a mental patient bussed to another state with nothinbg.Is that person still in charge of the facility that was doing this?

  4. Part 1 of 2

    While all of the "special procedures" described in the story above, not followed in Nevada, are very nice and kind to the mentally ill, there is but one reality. The State of Nevada's Governor and Legislature have chosen NOT to direct an endless supply of money to programs than Rawson-Neal. In 2012 J. Patrick Coolican wrote a story detailing the State's expenditures on programs for the mentally ill, which at that time compared favorably with those of other states. See: http://www.lasvegassun.com/news/2012/mar...

    The Sacramento Bee story above fails to disclose the existence of any Federal law or Federal hospital regulation requiring any procedures other than what Rawson-Neal does in providing transportation for mentally ill people who want to leave the city. That is the crux of the issue: No Federal law or regulation = The State of Nevada is free to set its own policies on discharge of the mentally ill from public hospitals.

    As to Rawson-Neal's patient discharge planners, it would be very unusual if they didn't ask the patient: "Where does your family live?" "Where is your home state?" I suspect those questions are asked, because they are asked by discharge planners in "regular" hospitals all across Clark County. I suspect a large number of Rawson-Neal patients are capable of answering those questions. I also suspect that a large number of Rawson-Neal patients indicate that they "Want to go home" after being incarcerated by the State of Nevada in the Rawson-Neal lockdown. What are the Rawson-Neal discharge planners supposed to do, in the minds of the authors of the story above? Say "Well here's the door and good luck to you in getting home." Alternatively, say "Even though you are not a danger to yourself and others, we are going to incarcerate you here in Nevada, indefinitely."

    To me, this story from the Sacramento Bee is very suspect. My belief is that it is designed to distract from California's own massive problems in dealing with homeless, mentally ill people. They are problems which have existed for at least 35 years. If anything, the problems are getting worse: California's Governor is a Democrat who line item vetoed from his state's budget all funds to treat mentally ill school children, which IS required by the Federal law called IDEA. California's Legislature is fully controlled by Democrats. Neither they nor their Governor have adequately funded mental health care facilities for the state's massive homeless population. Instead, the state's community mental health care budgets have been cut, despite California having a massive corps of well paid state employees with generous benefits

  5. Part 2 of 2

    To see the scope of California's problems in dealing with the mentally ill, one need only stay in the "nice" Downtown LA hotel formerly called the New Otani, to see, as dusk falls, more than a square mile of sidewalks covered with sleeping bags and other gear of homeless people, who, sadly are both dirty and hungry. Los Angeles area hospitals are infamous for discharging mentally ill patients and sending them that Skid Row area in taxi cabs.

    Los Angeles' neighborhood called Venice Beach and its famed boardwalk is bumper-to-bumper panhandlers, many of whom are clearly mentally ill. There are so many mentally ill panhandlers on that boardwalk, tourist traffic has dramatially dropped. That beachside boardwalk used to be Southern California's #2 tourist destination.

    Nearby Santa Monica's City Hall's green, grassy front lawn used to be covered with homeless people, camping out at night. Last time I was in Santa Monica for dinner, I saw that city turn on its front lawn sprinklers in the evening, quite obviously sending the homeless people a message: Stay out. I've run into these homeless people during the day, when they panhandle in the next-door convention center's parking lot and all I've encountered are clearly confused, drugged or mentally ill.

    The point is that none of those people are being cared for by the State of California and its elected officials, who are juggling the budget of what is, in essence, an insolvent state where its needs and economic obligations far exceed the state's cash flow.

    For too long, the Sacramento Bee has been failing to expose the multitude of foibles of the State's high level elected officials who are Democrats and the foibles of the state's high level employees.

    A high level employee of the state's toxic clean-up agency throwing a deposition in a Federal court case, so the state's laws would be invalidated and the radioactive waste polluted property owner would win? No coverage.

    Democrat elected officials on the board of directors of the state employees' pension fund making a $1 Billion investment in a land development company in early 2007 which went into bankruptcy in less than a year...when those elected officials were warned not to invest, before the investment was made? Coy coverage which did not implicate any of the Democrat elected officials in what ended up being a loss of more than $1 Billion in state employee pension money.

    Important story after story about California's dire state of affairs ignored by the Sacramento Bee.

    Perhaps, instead of being the pot calling the kettle black, the Sacramento Bee should be doing its job as the newspaper of record of California's state capital: Writing about the dire state of mental health care of the poor and the homeless in California.

  6. This goes back to when Ronald Reagan shut down the Mental Institutions because they were "not hurting anyone" to make room for some of the largest tax cuts the wealthy had ever seen in their lives - at that time. Well there is a price to pay and unfortunaltely it's always paid be the most vulnerable in our society. Shame on our Politicians.

  7. newnvres- Reagan didn't. SCOTUS case O'Connor vs. Donaldson in 1975 did that.

    Remember when Republican Mayor Giuliani did the courageous thing to help the mentally ill on the street had them taken to Bellevue for help but the ACLU stepped in and stopped him because they have the right to be crazy and live on the street. A great win for the ACLU who promptly went home and didn't careless what happened to those people. But yeah it's all Reagan's fault.

  8. Comment removed by moderator. Personal Attack

  9. l would not be surprised to hear this tactic is being used by many states in this country. Just another story to define the New American Way.

  10. $500 a day per "client", it would be cheaper to put them on a cruise ship.. I just saying that seems like a lot of money to house someone, what does the military spend housing soldiers per day?
    I am lost at the fact no mention about where the families of these mentally ill people are or why they do not take care of them and leave it up to the government?