An ‘ugly’ process: Sheriffs, hospitals shoulder burden of crisis mental health care in rural Nevada
No one knows why, but the mental health calls always seem to come in spurts.
Just last month, Lincoln County High School went on lockdown twice, once one week and again the next. A woman wandered onto the campus, extremely paranoid, afraid people were after her and speaking in gibberish. The next week, a man wandered into the lobby of the school, asked for a piece of paper and started writing out numbers and letters. He then went out into the common area where kids were milling about before school, started yelling and ripped his shirt off.
In each case, the sheriff’s office picked up the individual from the school in Panaca, filled out the paperwork to place the person on a mental health hold and drove them 166 miles south to University Medical Center in Las Vegas. In each case, someone experiencing an acute mental health crisis but who had committed no crime spent two and a half hours riding in the back of a police car, and a deputy trained for the nuances of everyday policing spent five hours off the streets and in the car, trying to get the person to help.
Transportation is a problem, but the situation is even worse if there’s nowhere for law enforcement to immediately take the person. In those cases, a patient may sit in an emergency room for 72 hours or longer just waiting to be taken somewhere to receive the treatment they need; if they are violent, a deputy may be assigned to watch over them around the clock until they’re transferred.
Several rural sheriffs, in interviews with The Nevada Independent, said they know that the back of their police car or, in some cases, a jail cell is not the best place for a person experiencing a mental health crisis. But sometimes there’s no other option.
“I guess I could just say one word. My first word is ugly,” said Lincoln County Sheriff Kerry Lee. “It’s not a pretty process.”
Nevada suffers from a shortage of mental health resources statewide, landing in 51st place in Mental Health America’s state rankings again this year. The problem is particularly severe in the state’s rural and frontier counties, where the burden of ensuring that people in need of acute mental health care receive the treatment they need often falls on the shoulders of rural emergency rooms and law enforcement.
And compared to some of the other counties, Lee said Lincoln is “fairly fortunate.”
“I’ve listened to some of the horror stories in Eureka, White Pine, some of these ones that are farther in the middle of the state,” Lee said. “They’ve got to try to get to Las Vegas or Reno.”
Not only do patients have to be transported 116 miles from the Eureka County jail to the hospital in Elko for medical clearance to be put on a mental health hold, but if they require in-patient medical treatment, they then have to travel 116 miles back to the jail in Eureka, where they will wait in a holding cell until a bed in Reno opens up — another 240-mile journey. With no hospital in the entire 4,180 square mile county, it’s the safest place to keep them, said Eureka County Sheriff Keith Logan.
There have been a number of steps in recent years to improve mental health care in the rurals, including mobile outreach safety teams that can stabilize individuals in the community before they reach high levels of crisis, crisis intervention training for law enforcement and increased use of telemedicine to virtually connect patients in rural hospitals to licensed clinical social workers. But both sheriffs and hospitals in the rurals say there’s still more that needs to be done.
“I don’t think it’s a stretch at all for any person to say that we have a mental-health situation problem here in America and certainly here in Nevada,” Logan said. “How do we deliver those services to people when they need it?”
An ‘ugly’ process
If you talk to sheriffs or hospital staff, they’ll tell you there’s no typical scenario for what happens when someone is experiencing mental health issues and is possibly a danger to themselves or others, though there are some common threads.
In Pershing County, Sheriff Jerry Allen describes his community as a “small fish in a big pond.” His agency and the hospital do the best they can for patients struggling with acute mental health needs, but connecting them with services — and figuring out what to do with them in the meantime — isn’t always easy.
For instance, a deputy might get a call about someone who is acting erratically but hasn’t committed a crime. If they seem to be a danger to themselves or others, the deputy might take the person to Pershing General Hospital in Lovelock to place them on a 72-hour involuntary mental health hold, known in Nevada as a Legal 2000.
At the hospital, the patient will be evaluated to see whether they meet the criteria for the 72-hour hold, namely that they have presented a clear and present danger of harm to themselves or others within the preceding 30 days as a result of mental illness and are “medically clear,” meaning they aren’t suffering from another medical problem causing or contributing to their psychiatric symptoms. Harm to self may include things like being unable to care for themselves, threats of suicide or self-mutilation, while harm to others usually includes attempts or threats to inflict serious bodily harm on others.
If the patient is intoxicated, law enforcement or hospital workers have to wait until they sober up to see if that resolves their thoughts of suicide or harm to others. Intoxicated individuals cannot be placed on a 72-hour psychiatric hold.
If the person meets all the criteria to qualify for a hold and needs further treatment, they often have to wait in the emergency room until an in-patient psychiatric treatment facility opens up, either at a state-run or private facility, typically in Reno or Sparks in the north (or Las Vegas for some of the counties further south.) If the person is rowdy or combative, the sheriff often stations a deputy at the hospital to watch over the patient until they can be transferred.
Christina Dickerman, chief nursing officer at Pershing General Hospital, said that the hospital has gotten lucky lately and been able to transfer some patients to the Mallory Behavioral Health Crisis Center, an emergency mental health center in Carson City that opened in January 2017. But if a bed isn’t immediately available, it becomes a question of what the hospital can do to care for the patient in the meantime.
“They’re here and they’re waiting, and we’re an emergency department and an acute care hospital. We don’t know what to do for these people and how to help them,” Dickerman said. “To me that’s a bigger thing. They’re hanging out and staring at a wall.”
The hospital uses a telemedicine system known as VSee to have patients evaluated by the state’s licensed clinical social workers and has also been trying to connect anyone who needs to stay in the hospital with psychiatrists at Renown Health in Reno, as almost all of the state’s psychiatrists are in Clark and Washoe counties.
“It would be really great to get a recommendation from a psychiatrist. Put them on Zoloft, something to help us get them started on the path to wellness,” Dickerman said.
If a bed isn’t available within 72 hours, that’s when Pershing County District Attorney Bryce Shields gets involved, going to court to request an extension of the hold. He said an extension is required in almost every case he gets involved in, which is usually about one every other month.
Once a bed finally does open up, it typically falls on Allen and his deputies to transport the patient to whatever facility they need to go to, usually a state-run facility if the patient is uninsured. It’s about a 90-mile drive from Lovelock to Reno, and Allen typically requires two deputies to make the trip together.
For Allen, leaving an officer stationed at the hospital or assigning two to drive a patient to Reno means fewer officers left to patrol in the county. The Pershing County Sheriff’s Office only has 15 patrol and detention officers combined and is currently running two positions down.
“It truly does drain our resources when we have a mental health patient come into our area,” Allen said.
Not all counties rely on law enforcement as heavily to help those in the midst of a mental health crisis, though, and a lot of it has to do with access to services.
Sheriff Ken Furlong said the system works “pretty well” in Carson City, in large part because of the close proximity of Carson Tahoe Behavioral Health and Mallory. Patients who have not been charged with a crime fall to the hospitals, while those who have are kept in the jails.
“It is extremely beneficial because we have these capabilities. It doesn’t mean we’re perfect, and God help me we’re not,” Furlong said. “It’s so sad when a person with a mental health disorder is sitting in jail waiting for a bed.”
But even with care nearby, wait times can still be a concern, Furlong said.
“Across the board, at least in this region, it is well acknowledged that jails and ERs, they’re not the place to treat mental health,” Furlong said. “We have to get them to the professionals, and there is substantial concern about how long it takes to get them there.”
Still, Carson City Assistant District Attorney Kristin Luis said that she hasn’t had any requested extensions of the 72-hour mental health hold recently. Lyon County District Attorney Stephen Rye and Douglas County District Attorney Mark Jackson said that they haven’t had to file for extensions of the hold either.
The extensions do happen in White Pine County, though. William Bee Ririe CEO Matt Walker said his hospital has held patients for up to a week waiting for a bed to open up, which requires going back to the judge in Ely for a 72-hour extension of the original 72-hour hold.
Walker said that the hospital has been told before that an accepting facility could “probably” take a patient, but when the facility is notified the patient is uninsured — which they oftentimes are — suddenly the beds are full.
“I know it’s not legitimate,” Walker said.
And even when a bed opens up, it’s a matter of getting the patient there between the sheriff’s office and the mostly volunteer ambulance service. Walker said they can sometimes beg a life flight team to take a patient, saving a 320-mile drive to Reno or a 245-mile drive to Las Vegas.
In Lincoln County, it’s the deputies who are often responsible for transporting patients, or, sometimes if the person is medicated and non-violent, a local ambulance will transport the person to the county line, where a Clark County ambulance will pick them up and transport them to an accepting facility.
“I’m such a small department. You can imagine what happens if, all of a sudden, I have to start transporting L2Ks to Las Vegas,” Lee, the Lincoln County sheriff, said. “It comes and goes. We have our busy spurts and slow spurts, but lately it’s been crazy.”
If someone comes in with a mental health issue and has committed a crime, Lee can keep the person in jail until they’re transferred to a forensic psychiatric facility, where it can be determined whether they are competent to stand trial. Lake’s Crossing in Sparks used to serve all the state’s forensic patients, though the renovated Stein Hospital on the campus of Rawson-Neal in Las Vegas now also accommodates forensic patients.
The more complicated situation, Lee said, is what to do with someone who hasn’t committed a crime if a bed isn’t immediately available.
“It’s not a crime to have mental health issues. So they’re like, ‘Hey, listen, we don’t have a bed for three days.’ Okay, what do we do with this person in the midst of the three days?” Lee said. “I can’t take them to jail. I would be up for charges. The hospital says, ‘We don’t have beds. We don’t want to keep them for three days.’ So what do we do for three days?”
Lee said that UMC has been “phenomenal” lately in taking patients who otherwise would have nowhere else to go.
“They’re good, good people. I just can’t say enough for those guys down there, especially for us rural counties. They try to get us in, try to get us back out,” Lee said.
As a public safety-net hospital, UMC will take all the patients that walk through the doors, even though it doesn’t have any psychiatric beds. But the emergency room isn’t the right place for patients struggling with acute mental health issues either, says Dr. Dale Carrison, UMC’s chairman of emergency medicine.
“Emergency departments and hospitals that don’t have mental beds in them, they don’t have the resources either,” Carrison said. “We can treat them medically, but we can’t treat them mentally.”
Carrison said that if an emergency room is slow and only turns over a bed every six hours, that means that one patient suffering from mental health issues occupying a bed for 48 hours has prevented eight patients from seeing a doctor. Mental health patients end up in the emergency department because they need medical clearance, but less than one percent of them typically have medical issues that need to be addressed, he added.
The issue comes down to who is ultimately responsible for these patients. If not emergency rooms, who? If not law enforcement, who?
“To have law enforcement responsible is silly. Law enforcement doesn’t have any resources to ‘treat’ these people,” Carrison said. “They have no resources at all.”
A ‘quilt’ of solutions
In Eureka County — the second least populous county in Nevada, 240 miles from Reno, 320 miles from Las Vegas and with no hospital — the responsibility of ensuring that people experiencing an acute mental health crisis are connected with the help they need falls on law enforcement.
Law enforcement are responsible for shepherding people suffering from a severe mental health crisis to the hospital, typically in Elko, for medical clearance and then back to a holding cell at the jail in Eureka, which Logan said is the safest location to keep them. Then, once a bed opens up, it’s another three hour and 45 minute drive to Reno or five hours to Las Vegas.
“We’re all trying to figure it out and make it work to the best of our ability,” Logan said. “We want to deliver services. We want folks to be treated.”
It’s a drain on the resources of the sheriff’s office, which only has 10 sworn officers and one of those positions currently vacant, but it’s also not the best way to help people who need immediate mental health care, Logan said.
“We want to be the destination of truly delivering appropriate services to people who need them at the appropriate time,” Logan said.
Dr. Lesley Dickson, executive director of the Nevada Psychiatric Association, said that she is sympathetic to law enforcement officers who are trying to respond to mental health crises.
“It’s not easy. They’re not trained to know how to deal with these potentially violent or very, very agitated or suicidal patients. They’re not trained to know how and they don’t have anyone there to help them,” Dickson said. “They probably don’t know what medications to use and they can’t anyway because they don’t have a doctor to do it. It’s a very unfortunate situation.”
To that end, the sheriff’s office is hoping to strike up an agreement with WestCare, a nonprofit that provides mental health and substance abuse services with locations in Las Vegas, Reno and Pahrump, to provide mental health services via telemedicine in the jail itself. A spokesman for WestCare did not respond to an inquiry for further information about the potential partnership.
The telemedicine system, which Logan hopes could be up and running in the next 60 days, would allow the sheriff’s offices to provide mental health services to both people housed in their jail as well as those with no criminal charges but in need of immediate help. Logan also envisions the possibility of being able to move the system to the public section of the building in order to deliver mental health services to the community at large if needed.
He said he would also like to see some kind of crisis mental health facility like Mallory but closer, such as in Elko or Winnemucca, or an in-person counselor who could serve both the jail and community in Eureka and other nearby counties.
“It’s just like a grocery store,” Logan said. “How many customers are you going to get through the door to make it a functioning viable product?"
Lee is also hoping that Lincoln County can establish a relationship with WestCare in the next two to six months to provide jail-based mental health services to figure out whether the person really needs to be transported to Las Vegas or can be kept in the community after receiving some telemedicine-based help. If it can save him a couple of trips to Las Vegas, the telemedicine system will pay for itself, Lee said.
But mental health is also not a conversation that communities have to have alone anymore. A bill passed during the 2017 legislative session designated four behavioral health regions in the state, created a regional behavioral health policy board for each and allows each to submit one bill draft request each legislative session.
Walker, the William Bee Ririe CEO, sits on the Rural Behavioral Health Policy Board and is hopeful that the group will be able to bring some fixes before the Legislature in 2019.
“It’s hard to blame any one person, and it’s a difficult problem,” Walker said. “We’re brainstorming like crazy because it is such a big issue but there’s no easy fix.”
Despite the addition of more private psychiatric beds in recent years, patients still can face a wait before getting the treatment they need.
Rawson-Neal sometimes has a wait time of up to three days once the documentation is completed to transfer them, hospital administrator Joanne Malay said. The court requires patients to be admitted to Lake’s Crossing or the forensic beds at Rawson-Neal within seven days, Dr. Elizabeth Neighbors, statewide forensic program director, said.
The ultimate goal for Jessica Flood, the regional behavioral health coordinator for Carson City and Churchill, Douglas, Lyon, Mineral and Storey counties, is keeping people in their communities while ensuring they have access to the mental health care they need. She said the lack of beds is a problem but that it would be even better if people weren’t required to travel four to six hours outside of their community just to get treatment.
“Inpatient psychiatric hospitals are really about medication management and some very brief therapeutic interventions. If you don’t have psychosis — and even if you have active psychosis — you bring them into a psychiatric hospital, five days, they start clearing up, you send them back to their community,” Flood said. “If they’re not going to connect with active treatment and they get psychotic again, was that intervention worth it?”
In recent years, mobile outreach safety teams have been formed by pairing a clinical social worker with a police officer to head off metal health crises before they further escalate, law enforcement and other community members have been offered crisis intervention training and telemedicine has been used to get quicker access to mental health care in the rurals.
The rural mobile outreach team, which is part state funded and part grant funded, is required to be out within two days to respond to checks on welfare, said DuAne Young, deputy administrator of clinical services for the Department of Public and Behavioral Health since February. Young acknowledged that the team can respond to calls in Elko or Fallon much more quickly than they can to those from White Pine.
The state is also in the beginning stages of a workgroup to address issues with the 72-hour hold process, including piloting a new process to help streamline the paperwork for the holds.
To get faster access to mental health care in the rurals, Nevada Rural Hospital Partners received a grant a few years ago to develop the telehealth program that allows rural health care providers and patients to connect through a platform called VSee with the state’s licensed clinical social workers Monday through Friday, 8 a.m. to 5 p.m. The licensed clinical social workers can access the patient’s records to see if they’ve utilized the state’s mental health facilities previously and determine whether the person needs to be transported for in-patient treatment or if they’re safe to go back into their community.
Joan Hall, CEO of Nevada Rural Hospital Partners, said that the program has deterred 50 percent of the number of transports to in-patient mental health facilities that otherwise could have occurred. But for the patients who do need more extensive treatment, finding access and transportation can still be a challenge, she said.
“When you think about these patients who are having the worst day of their lives — they’ve been in a police car all day, going to get medically cleared, going back to jail, and then going to Reno — the process has some issues nationally and in rural areas it is an issue,” Hall said.
Hall said that she’s been working with the state to see if the state’s psychiatrists can participate in some sort of tele-psych program that would allow hospitals to start administering any necessary medications while patients await further treatment. Young said that Dr. Leon Ravin, the state’s acting chief medical officer, has been working with the psychiatrists to get them comfortable doing psychiatry via telehealth while still meeting the standard of care they want to meet.
“We’ve helped to get those psychiatrists comfortable, so they’re still looking at the body language and meeting that standard of care,” Young said.
Nevada was also one of eight states to receive a grant from the Substance Abuse and Mental Health Services Administration to pilot Certified Community Behavioral Health Clinics in December 2016. Two of the state’s four clinics are in Elko and Fallon, which offer 24-hour mobile crisis response and provide walk-in access for behavioral health issues.
Young acknowledged that the two clinics aren’t the “comprehensive solution” everyone wants, but said the state is trying to do the best it can based on the resources available. Hall, Flood and some sheriffs suggested the best case scenario long term would be opening behavioral health clinics or crisis centers similar to Mallory in the rurals, though it’s unclear if the funding or patient population exists to sustain such a proposal.
In the shorter term, the focus will likely remain on increasing access to telemedicine for mental health in the rurals, supporting outreach and crisis intervention and brainstorming ideas for the 2019 legislative session. Hall said everyone is trying and that she’d like to be hopeful.
“It’s kind of a quilt that we’re trying to build,” Hall said.