Dan Morain

Dan Morain: Vegas' dicey mental policy

Dan Morain
Dan Morain

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LAS VEGAS – Like much in Vegas, the façade of Rawson-Neal Psychiatric Hospital is deceiving.

With its vaulted ceilings, large windows and tasteful Southwestern landscaping, Rawson-Neal is the sort of institution that receives glowing reviews in trade journals.

"Reflecting the natural environment, soft desert colors blend to create a warm, welcoming, and nonthreatening environment for psychiatric care," Behavioral Health Care magazine wrote in 2007 not long after Rawson-Neal opened.

But in 2007, Nevada lawmakers began cutting mental health funding. The facility is licensed to house 289 patients. But the staff is sufficient for 190, this in a metropolitan area of 1.9 million people.

Nevada's mental health system consistently ranks near the bottom of all 50 states. Its struggles spilled into California three weeks ago when Rawson-Neal gave a three-day supply of the antipsychotic drug thorazine to a chronic mentally ill man named James Flavy Coy Brown, and bought him a one-way Greyhound bus ticket to Sacramento.

Brown showed up 15 hours later, on Feb. 12, at the Loaves & Fishes homeless mission, holding discharge papers from Southern Nevada Adult Mental Health Services, which includes Rawson-Neal. He had no money and no idea where to turn.

Loaves & Fishes social worker Molly Simones called my colleague, Cynthia Hubert, who described the shocking story on the front page a week ago Friday, prompting politicians in both states to call for investigations. I went to Vegas with questions of my own.

Chelsea Szklany, Rawson-Neal's administrator, sat in a Rawson-Neal conference room, and told me how she has spent her career trying to help mentally ill people. She would never dump patients, she said. She also was not exactly sure of the facts that led to Brown's release.

"The facts of this case probably aren't all disclosed at this point," Szklany said. "I'm not convinced it is totally an inappropriate disposition in this case. But again, I take it very seriously."

Szklany and her boss, Nevada State Health Officer Tracey Green, will release the results of their investigation in about a month.

"It is not usual for us, and it is not a pattern," Green said by phone, referring to the apparent circumstances of Brown's release. "If there has been a policy variation and or a problem, we are going to find out and we're going to do something about it."

I asked Szklany for Rawson-Neal's records of bus ticket purchases to California for a six-month period. The department provided me with a summary showing that Nevada paid to bus 82 Rawson-Neal patients to California in the six months between last July and this January.

Of them, 66 "were California residents with state issued IDs, driver's license, Medi-Cal cards, family residence, or birth place information."

Eight had family, spouses or friends in California. Six patients "communicated a preference for treatment in/return to California for personal reasons." Two were bused to international airports for flights to some other location.

It's not clear why the patients' families and friends didn't pay their way home. Nor is it known how the 82 people fared upon their return to California. Officials cite federal privacy law to deny details about patients.

Rawson-Neal staffers won't talk publicly for fear of jeopardizing their jobs. But a social worker told me on condition of anonymity that budget cuts mean Rawson-Neal employees are overworked, that Las Vegas has too few shelters, and that what happened to Brown "is not isolated."

"California is seen as having much better services than this state for mental health care," the social worker said. "In a way, what we do is bad. But we know we don't have services here."

I don't doubt Green and Szklany's sincerity. But without knowing details about the individuals who were bused to California, it's impossible to know whether Nevada employs Greyhound Therapy as a way of solving its problem of mentally ill homeless people. That said, the mental health agency's policies, and the number of people bused to California in one six-month period from a single Nevada hospital, raise serious questions.

Although Las Vegas and Sacramento are very different, the metropolitan areas have roughly equal populations. Sacramento County mental health care officials report that they bused only five individuals to other states in the past year.

Nevada has honed its policy, developing, for example, a "nourishment protocol." Rather than send individuals on buses with sandwiches or lunch vouchers, Rawson-Neal provides bottles of Ensure.

"Ensure Plus is a healthier choice than most meals or snack items," the policy says. Six bottles suffice for a day trip, nine bottles for a trip lasting a day and a half trip. Brown's paperwork shows he received Ensure.

Szklany's predecessor, Stuart Ghertner, resigned last year as director of the Southern Nevada Adult Mental Health Services, after weathering more than $20 million in budget cuts, reducing his budget to $86 million.

"You reach a point where that was enough," Ghertner told me. "I felt like I had done as much as I could do."

Ghertner had approved the 2011 update to Rawson-Neal's transportation policy. Its intent is humane. The policy gives officials the authority to buy bus tickets home for mentally ill patients, if that's what they want.

The policy also directs case workers to make certain that someone is available to receive the patients at the other end of the bus trip. Brown's paperwork includes nothing about what people in Ghertner's line of work call a "warm hand-off."

"So why wasn't the policy followed? I have no idea," Ghertner said. "Under my watch, someone would have been notified that he was coming, and would have agreed to pick up the person."

At Loaves & Fishes, Brown explained to Simones that he had been living at a group home called Annie's Place with four roommates, but that home closed.

After about three weeks at Rawson-Neal, Brown told Simones, the hospital gave him and his former housemates bus tickets to San Diego, Los Angeles, San Francisco, Seattle and, in Brown's case, Sacramento.

Perhaps Brown was confused. There once was, for example, a group home in Las Vegas called Annie's Place. But Annie's Place closed in 2007 and never housed mentally ill people; it was for elderly individuals, its former owner told me.

Although some details might be wrong, Brown clearly arrived in Sacramento without a plan for his care, other than what he said a psychiatrist told him, to call an ambulance. As it happened, a Sacramento cop delivered him to Loaves & Fishes.

Patient dumping happens. Institutions release mentally ill people all the time. I recently wrote about how Sacramento County jailers released a mentally ill man, Matthew Herrera, in a paper jumpsuit and flip-flops at the start of the Presidents Day weekend. He was arrested 31 hours later after he stole and crashed his mother's car. He is back in jail.

Sacramento County authorities no doubt have made mistakes over the years. But there are clear differences between what Nevada did and didn't do for Brown, and how Sacramento mental health officials treat patients who are released.

Nevada provided Brown with three days' worth of medication, no doubt a money-saver. Sacramento County's mental health treatment center provides patients with a 30-day supply of medication, knowing that it may take time to fill prescriptions and that medication helps them remain stable.

Nevada's policy makes clear that cost is an issue: "It shall be the policy of Southern Nevada Adult Mental Health Services to assist patients who may be transported back to their home community in order to provide more appropriate care and to remove the burden of treatment from the state of Nevada."

Sacramento's policy governing patient release makes no mention of "the burden of treatment."

"The continuity of care is the most important thing," said Dorian Kittrell, executive director of the Sacramento County Mental Health Treatment Center.

Continuity costs money. Brown's care came cheap: a cab ride to the Greyhound depot, a $60 bus ticket, and a few cans of Ensure. Brown since has disappeared. He probably is wandering the streets.

"We hope every day that Mr. Brown is found and he is safe and, God willing, that he is not dead and nothing has happened to him," Nevada Health Officer Green said.

It's a nice sentiment. But now he's Sacramento's responsibility, not Nevada's. At Loaves & Fishes, Brown had said his voices were telling him to do something to get arrested, or jump off a bridge. He will turn up, one way or another.

Follow Dan Morain on Twitter @danielmorain.

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