Shades of Gray:
Dominican Santa Cruz Hospital/Jail Medical Facility


Providing care to chronic inebriates through a hospital emergency room is costly, particularly if they are medically indigent. Dominican Hospital and Santa Cruz County detention staff are in agreement that treating these alcohol and substance abusers is staff intensive. These patients often exhibit behavior problems, are homeless and have underlying medical conditions. The use of the Emergency Department at Dominican Hospital increases the cost of medical care, extends waiting time and diverts ambulances from other types of emergencies. Opinions differ, however, about who pays for patients not yet booked into jail. Dominican Hospital is required by federal law to provide emergency care regardless of a patient’s ability to pay. The county is responsible for medical care for prisoners under arrest, often serial inebriates or “frequent flyers.” When a detainee is in custody but not yet booked, Dominican Hospital often ends up delivering services and not receiving reimbursement within this “gray area.” Detention staff is exploring ways to decrease the cost of caring for serial inebriates, including establishing rehabilitation programs and a sobering facility and restructuring policies. Several other communities have started cost-effective, non-medical programs to divert inebriates from emergency rooms.


Booking: the process by which an arrestee is registered into the detention system

CHIP: California Health Care for the Indigent Program

Detainee: a person in custody

DUI: driving under the influence of intoxicating substances

ED: Emergency Department

EMTALA: Emergency Medical Treatment and Labor Act

ETOH: chemical or medical notation for ethyl alcohol

Frequent Flyers: persons who are frequently inebriated and brought to jail or the Emergency Department by law enforcement officers

Inebriate: one using alcohol or drugs to the point of intoxication

In custody: detained by law enforcement officers

LVN: Licensed Vocational Nurse


Medi-Cruz: a county-operated health care program that helps low-income residents of Santa Cruz County without health insurance to get the health care services they need

Netcom: Santa Cruz County’s computer-aided dispatch center

Proposition 36: The Substance Abuse and Crime Prevention Act of 2000 offers adults convicted of nonviolent drug possession offenses the opportunity for substance abuse treatment instead of incarceration.

RN: Registered Nurse

Safety chair: a restraining device in the Main Jail booking area for inmates with behavioral problems

Sallyport: a system of security doors in which the first door opens, then must be closed and locked before the second door will open

Triage: the process for evaluating casualties and assigning priority of treatment


According to detention personnel, the biggest drain on the jail’s medical budget is serial inebriates. These people are arrested for “Drunk in Public,” PC § 647(f) and can be brought to jail repeatedly.

When a person is arrested and taken to the county jail, he or she is first admitted through the booking sallyport[1] to a processing area. If arrestees are inebriated to the point of being unable to stand unassisted, they are taken to Dominican Hospital for medical evaluation. The jail nurse will not accept an injured arrestee because the jail does not have the necessary equipment and staff to treat the injuries. If the arrestee is not booked and taken to the hospital, he or she is responsible for the bill.

Dominican Hospital provides medical care to “county-responsible patients” under a Hospital Services Agreement with Santa Cruz County.[2] Persons under arrest by the Santa Cruz County Sheriff’s Department or incarcerated in the county jail are the responsibility of the county. Care of these often uninsured detainees increases the cost of medical care, extends waiting times in the Dominican Hospital Emergency Department (ED) and diverts ambulances from other types of emergencies.

Patients referred to the hospital from the jail sallyport prior to booking are treated as private pay patients. Many of these people are uninsured and also do not have Medi-Cal or Medi-Cruz. Their treatment, therefore, becomes a write-off for the hospital and the physicians who treat them. The bad debt (write-off) in the Emergency Department is significant. According to the Access to Medical Care Agreement (AMCA) between Dominican Hospital and Santa Cruz County, Dominican Hospital agrees to spend seven

percent of the hospital’s net operating expenses on uncompensated care, which include charity care and bad debts.

Once a person has been cleared for booking and accepted into the jail, any subsequent medical treatment the jail cannot provide is performed at the hospital. Santa Cruz County is responsible for the bill.

Hospitals in other counties and cities share the problem of uncompensated medical care. For example, Stanford University Medical Center sued the city of East Palo Alto and San Mateo County, accusing them of not paying for medical costs incurred by injured suspects brought in by East Palo Alto police. Stanford has a contract with the county to provide medical care to injured suspects.

San Diego, Portland, Phoenix, Seattle, Las Vegas and San Joaquin County have programs diverting public inebriates from emergency rooms. They have non-medical alternative placements for sobering up. Most use a combination of a sobering facility and local jails. The most cost-effective programs use vans to pick up public inebriates and bring them to the sobering programs.


This investigation began as a review of ways to improve medical care and to save money at the county’s main jail medical facility. In the course of the investigation, the issue of uncompensated care for detained but unbooked patients in county hospital emergency rooms emerged. Although Watsonville Community Hospital may also have this problem, we chose to focus on Dominican Hospital.



Dominican Santa Cruz Hospital personnel.

Santa Cruz County Health Services Agency personnel.

Santa Cruz County Main Jail medical personnel.

Santa Cruz County Sheriff’s Department personnel.



2003-2004 Santa Cruz Grand Jury Final Report, “Hospitals and Charity Care in Santa Cruz County.”

Application for California Healthcare for Indigents Program Funding for Fiscal Year 2004-5, May 4, 2005.

Board of Supervisors Meeting Minutes, January 4, 2005.



County of Santa Cruz and Dominican Santa Cruz Hospital, Hospital Services Agreement, [Article 2, § 2.1, (d)], signed in 1994, amendment signed in 1997.

Dominican Hospital Response, December 31, 2004.

Health Services Agency, Sheriff’s Department, Public Inebriate Summary, March 2003, EMS “Snapshot” with Estimated Annual Impacts.

Rama Khalsa, HSA Director, Mark Tracy, former Sheriff, Report Back on Emergency Room Issues Related to Criminal Justice and Public Inebriates, April 14, 2003.

Health Services Agency personnel, Follow-up Questions, May 4, 2005.

Steve Robbins, Sheriff – Coroner, Memo regarding study of inebriates at local hospital emergency rooms, April 27, 2005.

Newspaper/Magazine Articles

San Jose Mercury News, “Hospital sues for cost of treating suspects,” 2005.

Santa Cruz Sentinel, “County will offer drunks treatment,” July 27, 2004.

The Valley Post, “New Program Helping to Keep Inebriates Out of Emergency Rooms,” San Lorenzo Valley, February 15, 2005-March 14, 2005.

Web sites

City of San Diego, “Federal Government Lauds Local Efforts to End Chronic Homelessness,” September 4, 2004,

Centers for Medicare and Medicaid Services web site,

Santa Cruz County Personnel Department web site,


1.      In 1986, Congress enacted the Emergency Treatment and Labor Act (EMTALA) to ensure public access to emergency medical services regardless of ability to pay. Medicare-participating hospitals that offer emergency services must provide a medical screening examination when a request is made for examination or treatment for an emergency medical condition. Hospitals are required to provide stabilizing treatment for patients with emergency medical conditions [USC 42 § 1395(dd)].[3]

2.      Increased use of services is a key driver of rising hospital costs. While costs have continued to increase, reimbursements from government and many private health insurers have not kept pace. Increased use of Emergency Department services by patients not requiring this level of hospital care strains an already fragile emergency medical care system and may result in increased waiting times and ambulance diversion. Public inebriates consume hospital resources and could be better managed in alternative settings. Medically indigent inebriates further tax the system because they are uninsured.

3.      According to HSA personnel, emergency-room visits can be costly. At Dominican Hospital, it costs about $350,000 to $500,000 annually to treat indigent drunks.[4]

4.      A person can be booked “in absentia.” This happens if an arrestee has an immediate and serious medical condition that requires emergency medical treatment before going to jail. Santa Cruz County is responsible for medical care because the person under arrest is too injured to go to jail.

1.      In regard to medical clearance of an arrestee prior to booking, the jail nurse on duty triages[5] the arrestee at the door. If arrestees cannot stand on their own, they are taken to Dominican Hospital by the arresting agency for medical clearance. The cost of the medical care while at Dominican Hospital falls on the individual. If the individual cannot pay, Dominican Hospital assumes the cost. If an inmate needs hospitalization or treatment after booking, the financial responsibility belongs to the Sheriff’s budget.

2.      The safety room at the Main Jail (drunk tank) is not often used. Confining a detainee in the safety room requires frequent observation of the detainee. Another restraining device, the safety chair, can be used for a few hours at a time until the detainee “settles down.”

3.      Detention personnel said the biggest drain on the jail’s medical budget is “serial drunks.” These are people are arrested repeatedly for PC § 647(f) (Drunk in Public), a misdemeanor.

4.      Ambulances in California must bring patients to emergency rooms unless the patients have adequate mental capacity to refuse treatment and have no obvious injuries.

5.      Detention personnel say that handling inebriates is staff intensive. They often exhibit behavioral problems, are homeless and can have underlying medical problems. Some “frequent flyers” are recognized by detention nurses upon arrival as having chronic medical problems. Those needing treatment must be taken to the hospital Emergency Department. According to Detention personnel, the target group in Santa Cruz County is about 10 people who are routinely picked up for drunkenness.[6]

6.      According to Dominican Hospital personnel, in-custody patients who had used the Emergency Department while in custody sometimes return on their own to use it as a source of narcotics and as an alternative to “street-acquired” medications.

7.      Detainees do not have a large effect on staffing in the Emergency Department but can affect patient flow through the department. Having to perform Driving Under the Influence (DUI) blood draws may affect staffing because medical technicians are taken away from caring for other patients.

8.      When an officer picks up an inebriate in public, the inebriate is sometimes given the choice of going to jail or going to the hospital. According to Emergency Department personnel, the inebriate often chooses the hospital.

9.      Weekend and overnight shifts are more impacted by inebriates and drug users because they come in during those shifts more often. Staffing levels are lower during the night shift. If inebriates are medically stable, they may occupy a bed for eight to 10 hours to sober up. It usually takes at least four hours for a patient to sober up and be ready to discharge. Typically, an officer does not stay with them. For many of these patients, the reason they were detained is no longer applicable (i.e., public intoxication), and they are released without being charged.

10.  Inebriates are often brought to the hospital by ambulance. There are a total of 13 ambulances in service in the County of Santa Cruz (in and out of service at different times). If they are tied up on calls for inebriates, they cannot answer calls for other emergency situations.

11.  Detainees can be a factor in overwhelming an emergency room because frequently they arrive unannounced, especially if they are coming in a police car directly from being arrested. With an ambulance, the emergency room gets a few minutes’ warning. The emergency room could use that time to get a bed ready. If someone just “shows up,” there is more pressure to move people around.

12.  If inebriates come in off the street (for example, they were in a bar fight), they are evaluated by a physician to determine if they are sufficiently medically stable to go to jail. Those patients may arrive in an ambulance or a police car.


13.  In 1994, Dominican Hospital and Santa Cruz County signed a contract that specifies, “persons under arrest by the County Sheriff’s Department or incarcerated in the County jail” are county-responsible patients. The county is responsible for the cost of their health care.[7]

14.  Dominican Hospital accepts reimbursement for services from Santa Cruz County at a negotiated and agreed-upon rate.

15.  Dominican Hospital personnel say that early this year Detention administration implemented a new policy requiring that a triage nurse at the sallyport fill out the Medical Triage/Sallyport Refusal form and send it to the hospital with the officer and inebriate. Once individuals have been treated at the hospital and medically cleared, they are taken to jail for booking. All medical services provided prior to booking are now the financial responsibility of the individual. Despite the lack of health insurance/financial resources for many of these patients, the hospital is required by law to provide services but is not guaranteed any reimbursement. In addition, this new procedure requires that a new form must accompany the bill in order to secure payment for inmates transported to the hospital from county detention facilities. Dominican Hospital personnel say that this new procedure was put into effect without adequate communication about the changes to either Dominican Hospital or to law enforcement, creating much confusion.

16.  According to Dominican Hospital personnel, the approved patient payment is based on a hospital services agreement reimbursement contract. Reimbursement for outpatient care covers the cost of services. However, reimbursement for inpatient services does not cover total costs.

17.  According to Dominican Hospital personnel, patients in custody may require Emergency Department and other hospital services. Hospital personnel say that the costs of providing care should not be the responsibility of the hospital. Sometimes the hospital has no way to ascertain the booking status of a patient before providing services.

18.  HSA personnel said that whether the county is legally responsible for emergency room care for detainees who have not been formally booked is a “gray area.”

19.  There is a distinction between eligiblity for Medi-Cal and Medi-Cruz in Santa Cruz County. Medi-Cal recipients must meet certain criteria including income, citizenship, children and disabilities. Medi-Cal is a federal program administered by the state.

20.  Medi-Cruz is the county’s response to CA Government Code § 17000. It applies to people in the county who have no other resources, i.e., homeless, indigent, undocumented aliens or older people without children.

21.  Services available to Medi-Cruz recipients are:

·        primary health care in clinics;

·        X-rays;

·        pharmaceuticals;

·        emergency care; and

·        hospital (in-patient) care.

26.  Medi-Cruz does not cover jailed inmates. The medical costs for incarcerated patients come from the Detention Jail budget. Even if they are active Medi-Cruz patients, services cease after they are booked according to HSA personnel.

27.  According to Dominican Hospital personnel, there is a staff member at Dominican Hospital to assist people to sign up for Medi-Cruz and Medi-Cal. This position is not staffed 24 hours a day.

28.  Patients determined eligible for Medi-Cruz services can have treatment paid for retroactively. However, it is up to the client to cooperate and follow through with the paperwork for this to be accomplished.

29.  The medical budget for detention facilities is $3 million. The three largest components of the detention medical budget are:

·        nursing/medical care (salaries) within the jail;

·        services delivered at the county health clinics (X-rays, pharmacy and laboratory are the largest intra-agency cost); and

·        outside medical care (Doctors On Duty or dental care).

30.  CHIP funds may not be used to support health services provided to persons detained in a county or city jail or other correctional facility (W&I Code Section 16995).[8]

31.  HSA personnel believed that claims for indigent detainees might be partially covered by CHIP money. The amount of funding the county receives from CHIP doesn’t allow for 100 percent reimbursement of all of those claims. The total 2004-2005 CHIP allocation for Santa Cruz County is $77,214.

32.  According to HSA personnel, there is disagreement over who is financially responsible for blood draws and Breathalyzer tests done on detainees to determine drug and alcohol levels. The law is not specific, and it is an area of contention.

33.  The jail does not do Breathalyzer tests or blood draws on arrested subjects. Law enforcement officers perform Breathalyzer tests. The hospital does not have Breathalyzer equipment. Nurses at the Main Jail do not take blood alcohol levels. They cannot collect evidence.

34.  Hospital personnel must perform blood draws. As a result, this takes away from staff time to collect samples. Hospital staff is often called to testify in court regarding collection of such samples as evidence. Staff are not reimbursed for court appearances.

Procedural Alternatives

35.  A Santa Cruz County elected official says that legislation should be changed. People who are eligible for state medical benefits should not lose those benefits when incarcerated.

36.  According to a Dominican Hospital medical staff member, patients could be better handled at the jail if there were an infirmary on site. Once they are cleared medically, they should be able to be monitored on site at the jail.

37.  Detention Health Services intends to clarify in writing the criteria for transporting individuals to emergency departments for medical clearance prior to bringing them to jail. It appears that many people being brought to emergency departments could be brought to the jail directly by police officers. Training for police also appears necessary so that individuals are brought to the appropriate location.[9]

38.  Detention Medical staff is also evaluating current staffing patterns and hours to better serve this population in a cost-effective and clinically appropriate manner. Additional staffing may be required on Friday and Saturday nights for medical direction of these cases. This is a peak time for cases with alcohol and drug involvement. [10]

39.  Dominican Hospital staff has suggested that the jail medical facility should be sufficient to take care of inebriates if patients could receive intravenous treatment.

40.  Netcom staff is currently developing management reports based upon computer-aided-dispatch data to help determine when and how ambulances are dispatched for serial inebriates, as well as the involvement of law enforcement from different jurisdictions. Because of the law forbidding alternate destinations,[11] the best way to reduce emergency room use for this purpose is to not have law enforcement call for an ambulance solely for public inebriates. Once Netcom is contacted to dispatch an ambulance, national medical procedures do not give them broad latitude in these areas.

41.  According to Dominican Hospital personnel, the Main Jail could decrease use of the Emergency Department by providing the following services:

·        more advanced nursing assessment and triage at the medical triage/sallyport to decrease refusals;

·        observation and sobering;

·        wound evaluation and care; and

·        Breathalyzer and blood or urine alcohol testing.

42.  According to Dominican Hospital personnel, law enforcement manipulates the system by not arresting the client under the influence or only citing after sobering, thereby avoiding a booking fee/court appearance.

43.  According to Detention personnel and Dominican Hospital personnel, a previous sobering center in the county was closed due to a patient/inmate escaping and creating problems in the neighborhood.

44.  The Sheriff’s Department, Netcom and AMR, a local ambulance service, will be further analyzing local data and processes that lead to emergency room use.

Alternatives in Santa Cruz County

45.  Project Connect, a new program of the county’s Homeless Person’s Health Project, is a grant program administered through the Health Services Agency, designed to reduce misuse of emergency services such as ambulance, emergency rooms and fire services.

46.  Project Connect seeks out individuals who have had five or more ER visits in one year and enrolls them in an intensive case management process. Project Connect is funded by a $300,000 grant from the California Healthcare Foundation and The California Endowment. The funds pay primarily for staff who connect participants with outside agencies providing many services.

47.  In its first year of operation, Project Connect has seen a 43 percent decrease in emergency room visits, a 35 percent decrease in jail bookings and a 25 percent decrease in ambulance transports by its participants. Project Connect takes a holistic approach, helping people access primary health care but also supporting constructive life changes.

48.  In November of 2004, Santa Cruz County started a Serial Inebriate Program in hopes of decreasing the jail population and beginning some meaningful rehabilitation. This program is funded by a grant through HSA and involves the Probation Department, the District Attorney’s Office, the Public Defender’s Office and the Sheriff’s Department.

49.  In the Serial Inebriate Program, sentenced inmates can choose to serve their time at a sobering facility in Santa Cruz, located on 7th Avenue, in lieu of jail. For instance, they might have a choice of a specified jail sentence or serving the same amount of time in the rehabilitation program. According to detention personnel, the program is working well; although sometimes inmates have two or three failures before they commit to treatment.

50.  Under the Serial Inebriate Program, inebriates who are arrested three times go to detoxification or jail.

Serial Inebriate Program in San Diego County

51.  Started in January 2000, the Serial Inebriate Program is an innovative effort involving the City and County of San Diego, the San Diego Police and Sheriff's Departments, San Diego County Superior Courts, San Diego County Health and Human Services and Mental Health Systems, Inc. A number of agencies and treatment partners work in tandem with SIP. This collaborative effort provides a less expensive and more appropriate alternative to emergency departments and jails for treatment of homeless chronic inebriates. This program has had a dramatic effect on San Diego emergency departments.[12] In San Diego, the first year of the program saw 144 people enter the program. A year later, 58 percent had had no contact with police since leaving treatment.

52.  The goals of the Serial Inebriate Program (SIP) are to:

·        slow or stop the revolving door cycle of chronic alcoholics going in and out of detoxification centers, county jail and emergency rooms;

·        divert this population off the street and into county-funded treatment programs;

·        significantly reduce the uncompensated costs, time constraints and manpower burdens to San Diego County's healthcare, law enforcement and judicial infrastructure caused by homeless, chronic alcoholics; and

·        give people who routinely live on the street an opportunity to create a stable mainstream lifestyle.

53.  The program strategy offers treatment in a joint City/County-funded program in lieu of custody time resulting from a guilty verdict for public intoxication. Once in treatment, clients are provided with wraparound services designed to help their recovery from alcoholism and begin moving them toward re-entering society as a sober community member. [13]


1.      Providing medical care for serial inebriates, especially if they are medically indigent, raises Dominican Hospital’s operating expenses significantly. Those costs are absorbed by the consumer.

2.      Providing services to serial inebriates negatively impacts Emergency Department operations.

3.      Dominican Hospital and county personnel have different understandings of who is responsible for paying for medical care for patients who have been placed in custody but not booked.

4.      Dominican Hospital could improve its reimbursement rate by expanding the hours of staff who assist patients with the Medi-Cal and Medi-Cruz process.

5.      Since taxpayers and medical consumers ultimately cover uncompensated medical expenses, a cost-effective alternative to using the Emergency Department to treat inebriates would be a sobering center in the county. This would reduce the financial and workload burden on Dominican Hospital and Detention staff.

6.      Alternative programs in Santa Cruz County have been successful in reducing the number of frequent Emergency Department users. These programs depend on continued funding from Santa Cruz County or the State of California.

7.      Alternative programs in other cities and counties have been successful in reducing the number of serial inebriates. Drawing from the experience of these programs could prove beneficial to Santa Cruz County.


1.      The Health Services Agency should clarify procedures for reimbursement of medical costs for those in custody who have not been booked and communicate those procedures to Dominican Hospital.

2.      Law enforcement officers should continue to receive training in policies and procedures for transporting serial inebriates to the emergency room.

3.      Detention staff and HSA should explore the possibility of establishing a sobering facility in Santa Cruz County.

4.      Project Connect is to be commended for its success in reducing Emergency Department visits, jail bookings and ambulance transports.

5.      County officials should join in efforts to maintain funding for promising programs that assist serial inebriates in creating stable lifestyles for themselves.

6.      HSA and Detention staff should stay in communication with other cities and counties that have successful programs for serial inebriates and incorporate some of these ideas into Santa Cruz County programs.

7.      Santa Cruz County should investigate creative solutions to involve Dominican Hospital in solving the problem of frequent use of the Emergency Room by serial inebriates. The Access to Medical Care Agreement may provide the avenue to encourage collaboration.


Responses Required




Respond Within

Santa Cruz County Board of Supervisors



60 Days

(August 30, 2005)

Santa Cruz County Health Services Agency



90 Days

(September 30, 2005)

Santa Cruz County Sheriff



60 Days

(August 30, 2005)















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[1] See Definitions.

[2] County of Santa Cruz and Dominican Santa Cruz Hospital, Hospital Services Agreement.

[3] Centers for Medicare and Medicaid Services Web site,

[4] Santa Cruz Sentinel, “County will offer drunks treatment,” July 27, 2004.

[5] See Definitions.

[6] Santa Cruz Sentinel, “County will offer drunks treatment,” July 27, 2004.

[7] County of Santa Cruz and Dominican Hospital Services Agreement, 1994.

[8] Application for California Healthcare for Indigents Program Funding for Fiscal Year 2004-5, May 4, 2005.

[9] HSA Director, former Sheriff, Report Back on Emergency Room Issues Related to Criminal Justice and Public Inebriates, April 14, 2003.

[10] HSA Director, former Sheriff, Report Back on Emergency Room Issues Related to Criminal Justice and Public Inebriates, April 14, 2003.

[11] See Finding 1.

[12] HSA Director, former Sheriff, Report Back on Emergency Room Issues Related to Criminal Justice and Public Inebriates, April 14, 2003.

[13] City of San Diego, “Federal Government Lauds Local Efforts to End Chronic Homelessness,” September 4, 2004,