Providing care to chronic inebriates through a hospital
emergency room is costly, particularly if they are medically indigent.
Booking: the process by which an
arrestee is registered into the detention system
CHIP:
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
Netcom:
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
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
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.
Hospitals in other counties and cities share the problem of
uncompensated medical care. For example,
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
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
Application for
Board of Supervisors Meeting Minutes, January 4, 2005.
Health Services
Agency, Sheriff’s Department, Public Inebriate Summary, March 2003,
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.
San Jose Mercury News, “Hospital sues for cost of treating suspects,” 2005.
The Valley Post, “New Program Helping to Keep Inebriates Out of Emergency Rooms,” San Lorenzo Valley, February 15, 2005-March 14, 2005.
City of
Centers for Medicare and Medicaid Services web site, http://www.cms.hhs.gov/providers/emtala/default.asp.
Santa Cruz County Personnel Department web site, http://sccounty01.co.santa-cruz.ca.us/personnel/salsched/salsched.asp.
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
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.
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
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
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
6.
According to
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
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,
14.
15.
16. According
to
17. According
to
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
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
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
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.
35. A
36. According
to a
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.
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
· 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.
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,
49. In the
Serial Inebriate Program, sentenced inmates can choose to serve their time at a
sobering facility in
50. Under the Serial Inebriate Program, inebriates who are arrested three times go to detoxification or jail.
51. Started in
January 2000, the Serial Inebriate Program is an innovative effort involving
the City and
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
2. Providing services to serial inebriates negatively impacts Emergency Department operations.
3.
4.
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
6. Alternative
programs in
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
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
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
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
7.
Entity |
Findings |
Recommendations |
Respond Within |
|
|
1-53 |
1-7 |
60 Days (August 30, 2005) |
|
Santa Cruz County Health Services Agency |
1-53 |
1-7 |
90 Days (September 30, 2005) |
|
|
1-53 |
1-7 |
60 Days (August 30, 2005) |
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[1] See Definitions.
[2]
[3] Centers for Medicare and Medicaid Services Web site,
http://www.cms.hhs.gov/providers/emtala/default.asp.
[4]
[5] See Definitions.
[6]
[7]
[8]
Application for
[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