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
Sally port: 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 sally port[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 sally port
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,
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,
Steve Robbins,
Sheriff – Coroner, Memo regarding study of inebriates at local hospital
emergency rooms,
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]
Response:
Santa Cruz County Board of Supervisors AGREES.
Response: Santa Cruz County Sheriff's Office AGREES.
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.
Response: Santa Cruz County Board of Supervisors AGREES.
Response: Santa Cruz County Sheriff's Office AGREES.
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]
Response: Santa Cruz County Board of Supervisors AGREES.
Response: Santa Cruz County Sheriff's Office AGREES.
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.
Response:
Santa Cruz County Board of Supervisors PARTIALLY DISAGREES.
Police agencies do
have the authority to book a person “in absentia,” but this is usually only
done for shootings or serious high-risk crimes. In these incidents, the
prisoner is in the county’s custody, and the county is responsible for medical
care. However, because the person is in custody, there must also be a deputy
assigned to the hospital bed on a 24-hour basis, making this a very costly
situation. This type of booking only occurs once or twice a year.
Response: Santa Cruz County Sheriff's Office AGREES.
5. 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.
Response:
Santa Cruz County Board of Supervisors PARTIALLY AGREES.
Jail
nursing focuses not just on standing, but lapsing in and out of
consciousness. Patients are eligible for
Medi-Cruz if they are not covered for necessary care. Also, the California
Healthcare for the Indigent Program (CHIP) can be billed by doctors and
hospitals if the patient does not follow through with Medi-Cruz.
Response: Santa Cruz County Sheriff's Office AGREES.
6. 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.”
Response:
Santa Cruz County Board of Supervisors DISAGREES.
At the Main Jail,
the room used to hold intoxicated arrestees for several hours pending release
is different than the safety rooms used to hold inmates for brief periods who
may harm themselves. The safety chair is used to hold arrestees who cannot be
controlled by any other methods and techniques and who present a danger to
themselves or others. The safety chair is used infrequently. The booking area
has a room that can be used for intoxicated individuals.
Response: Santa Cruz County Sheriff's Office DISAGREES.
At the Main Jail, the room used to hold intoxicated arrestees for several hours pending release is different than the safety rooms where inmates who may harm themselves are placed for brief periods. The safety chair is used to hold arrestees who not able to be controlled by any other methods and techniques and present a danger to themselves or others, and is used infrequently.
7. 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.
Response:
Santa Cruz County Board of Supervisors DISAGREES.
Serial
inebriates take up significant amounts of staff time and can be very
disruptive, but they are not particularly expensive to treat. The highest costs
in the medical budget are paying for inmates who require emergency room care
and paying for long-term acute medical treatment of inmates.
Response: Santa Cruz County Sheriff's Office DISAGREES.
The highest cost of jail medical budget is staff salary, inmates sent to emergency rooms and
long-term admittance.
8. Ambulances in California must bring patients to emergency rooms unless the patients have adequate mental capacity to refuse treatment and have no obvious injuries.
Response: Santa Cruz County Board of Supervisors AGREES.
Response: Santa Cruz County Sheriff's Office AGREES.
9. 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]
Response:
Santa Cruz County Board of Supervisors PARTIALLY AGREES.
Treatment is only
sought for these patients if they have acute medical conditions needing
stabilization. Also, there are 30-40 individuals at any one time with routine
drunkeness in public as cause of arrest.
Response: Santa Cruz County Sheriff's Office AGREES.
10. 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.
Response: Santa Cruz County Board of Supervisors AGREES.
Response: Santa Cruz County Sheriff's Office AGREES.
11. 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.
Response: Santa Cruz County Board of Supervisors AGREES.
Response: Santa Cruz County Sheriff's Office AGREES.
12. 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.
Response: Santa Cruz County Board of Supervisors DISAGREES.
Law enforcement
agencies transport arrestees to the jail if possible and to the emergency room
in those cases in which the arrestee is in need of medical care or assessment
prior to being brought to booking.
Response: Santa Cruz County Sheriff's Office DISAGREES.
Law Enforcement agencies transport arrestees to the jail if possible and to the emergency room in those cases in which the arrestee is in need of medical care or assessment.
13. 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.
Response:
Santa Cruz County Board of Supervisors PARTIALLY AGREES.
Public
intoxication arrestees, with the exception of the identified frequent serial
inebriates, are not housed at the County Jail but are instead held in a room
for several hours until such a time as they can safely care for themselves.
This time frame is approximately five hours.
Response: Santa Cruz County Sheriff's Office PARTIALLY AGREES.
Public intoxication arrestees, with very few exceptions, are not housed
at the County Jail but instead are held in a room for several hours until such
time as they can care for themselves. This time period is most often approximately
five hours. During this detainment, they are observed every 15 minutes after
initial medical screening.
14. 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.
Response: Santa Cruz County Board of Supervisors AGREES.
Response: Santa Cruz County Sheriff's Office AGREES.
15. 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.
Response: Santa Cruz County Board of Supervisors AGREES.
Response: Santa Cruz County Sheriff's Office AGREES.
16. 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.
Response: Santa Cruz County Board of Supervisors AGREES.
Response: Santa Cruz County Sheriff's Office AGREES.
17. 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]
Response:
Santa Cruz County Board of Supervisors PARTIALLY AGREES.
All insurances,
including Medi-Cal, can be billed prior to booking in the jail and establishment
of prisoner status. The MADDY fund (state reimbursement for uncompensated
emergency medical care) can be billed for others who are not in prisoner status
in the jail. The Sheriff funding is specifically for prisoners and is the payor
of last resort. There are many jurisdictions doing arrests (Highway Patrol,
City Police Departments, State Parks, UCSC Police). With few exceptions, these
patients are not booked “in absentia” as described in #4.
Response: Santa Cruz County Sheriff's Office AGREES.
18. Dominican Hospital accepts reimbursement for services from Santa Cruz County at a negotiated and agreed-upon rate.
Response:
Santa Cruz County Board of Supervisors AGREES.
The
current rates are $955.00 per day inpatient and 70% of charges for outpatient
services, including Emergency Department services and all associated tests.
Response: Santa Cruz County Sheriff's Office AGREES.
19. Dominican Hospital personnel say that early this year Detention administration implemented a new policy requiring that a triage nurse at the sally port fill out the Medical Triage/Sally port 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.
Response:
Santa Cruz County Board of Supervisors PARTIALLY AGREES.
The
Sheriff and the Health Services Agency make every effort to communicate policy
and procedures with all parties concerning areas of mutual interest. Sheriff’s
Administration, Detention and the HSA chief met with Dominican Hospital fiscal
staff in early 2005 to address billing issues. Since that meeting, there have
been no issues or confusion regarding inmate billing.
Response: Santa Cruz County Sheriff's Office DISAGREES.
The Sheriff makes every effort to communicate policy and procedures
with all parties concerning areas of mutual interest. Sheriff's Administration, Detention and the HSA chief met with
Dominican Hospital fiscal staff in early 2005 to address billing issues. Since
that meeting, there have been no issues/confusion regarding inmate billing.
20. 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.
Response:
Santa Cruz County Board of Supervisors PARTIALLY AGREES.
The
reimbursement rate for inpatient days is below actual cost and the rate for ER
and outpatient exceeds actual costs.
Response: Santa Cruz County Sheriff's Office AGREES.
21. 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.
Response:
Santa Cruz County Board of Supervisors DISAGREES.
Booking
status can be determined by the officer who is accompanying the arrestee to the
hospital at time of patient intake. Booked prisoners sent to the ER/hospital by
the jail staff have a form authorizing treatment and describing the presenting
problem. Officers in the field are from
all jurisdictions and may not have referral forms. If an arrestee is
accompanied by an officer, it does not necessarily mean they have been booked
into custody.
Response: Santa Cruz County Sheriff's Office DISAGREES.
The hospital determines booking status from the officer who accompanies the arrestee to the hospital at the time of patient intake.
22. 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.”
Response:
Santa Cruz County Board of Supervisors DISAGREES.
Jail
Medical Services/Detention staff are not responsible for emergency room care
for persons who are not in custody (i.e., booked into jail or booked in
absentia).
Response: Santa Cruz County Sheriff's Office DISAGREES.
The Sheriff is not responsible for emergency room care for persons who
are not in the custody of the Sheriff. This topic was discussed at length (See
#19 response).
23. There is a distinction between eligibility 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.
Response: Santa Cruz County Board of Supervisors AGREES.
Response: Santa Cruz County Sheriff's Office AGREES.
24. 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.
Response: Santa Cruz County Board of Supervisors AGREES.
Response: Santa Cruz County Sheriff's Office AGREES.
25. Services available to Medi-Cruz recipients are:
· primary health care in clinics;
· X-rays;
· pharmaceuticals;
· emergency care; and
· hospital (in-patient) care.
Response:
Santa Cruz County Board of Supervisors PARTIALLY AGREES.
Medi-Cruz also
covers specialty services and some durable medical equipment.
Response: Santa Cruz County Sheriff's Office AGREES.
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.
Response: Santa Cruz County Board of Supervisors AGREES.
Response: Santa Cruz County Sheriff's Office AGREES.
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.
Response:
Santa Cruz County Board of Supervisors AGREES.
Medi-Cruz will pay
for medically necessary care prior to booking.
Response: Santa Cruz County Sheriff's Office AGREES.
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.
Response: Santa Cruz County Board of Supervisors AGREES.
Response: Santa Cruz County Sheriff's Office AGREES.
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).
Response:
Santa Cruz County Board of Supervisors AGREES.
Also included in outside
medical costs are Dominican and Watsonville Hospital services (both inpatient
and outpatient).
Response: Santa Cruz County Sheriff's Office AGREES.
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]
Response:
Santa Cruz County Board of Supervisors AGREES.
Medi-Cruz will pay
for medically necessary care prior to booking.
Response: Santa Cruz County Sheriff's Office AGREES.
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.
Response:
Santa Cruz County Board of Supervisors PARTIALLY AGREES.
If an individual
is not a booked inmate for whom Detention Health covers costs, other
funding sources may be available.
Response: Santa Cruz County Sheriff's Office AGREES.
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.
Response:
Santa Cruz County Board of Supervisors DISAGREES.
The arresting
agency is responsible for the payment of services such as blood draws and
Breathalyzer tests administered at the discretion of the arresting agency prior
to the booking process.
Response: Santa Cruz County Sheriff's Office DISAGREES.
The arresting agency is responsible for payment of services such as blood draws and Breathalyzer tests administered at the discretion of the arresting agency prior to the booking process.
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.
Response:
Santa Cruz County Board of Supervisors AGREES.
Response: Santa Cruz County Sheriff's Office AGREES.
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.
Response:
Santa Cruz County Board of Supervisors NEITHER AGREES NOR DISAGREES.
The
county cannot comment on this finding. The county has no knowledge as to
whether or not hospital staff is compensated by the court or private attorneys
for court appearances.
Response: Santa Cruz County Sheriff's Office PARTIALLY AGREES.
The Sheriff has no knowledge of whether or not hospital staff is compensated for court appearances.
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.
Response:
Santa Cruz County Board of Supervisors PARTIALLY AGREES.
The
county cannot comment on what an unnamed elected official may have said.
However, the county agrees that federal law unfairly burdens local law
enforcement by discontinuing Medi-Cal coverage for incarcerated persons.
Response: Santa Cruz County Sheriff's Office PARTIALLY AGREES.
The Sheriff has no knowledge of an official advocating an amendment to
state law and was never notified of any such amendment.
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.
Response:
Santa Cruz County Board of Supervisors PARTIALLY AGREES.
The
county cannot comment on what an unnamed medical staff member may have said,
but agrees that there is no current capacity for intensive care.
Response: Santa Cruz County Sheriff's Office AGREES.
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]
Response:
Santa Cruz County Board of Supervisors PARTIALLY AGREES.
Arrestees are
currently screened by jail medical personnel at the time of booking or housing
and are referred as needed by detention medical staff for medical
treatment. Training of officers may be
helpful, but only medical personnel can make the determination to refer to the
hospital. Health staff developed cards for the officers of all jurisdictions to
help them understand who goes to jail and who needs medical treatment or
screening.
Response: Santa Cruz County Sheriff's Office PARTIALLY AGREES.
Arrestees are currently screened by jail medical personnel at the time
of booking or housing and are referred to the hospital by jail medical staff.
Additional training to officers may be helpful, but it is jail medical that
makes the determination to refer to hospital.
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]
Response:
Santa Cruz County Board of Supervisors AGREES.
Response: Santa Cruz County Sheriff's Office AGREES.
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.
Response:
Santa Cruz County Board of Supervisors DISAGREES.
The
jail has an outpatient-housing unit for inmates needing medical treatment and
is not licensed to perform a level of care which would include intravenous
therapy. It would be cost-prohibitive for the jail to operate an on-site
licensed hospital.
Response: Santa Cruz County Sheriff's Office PARTIALLY AGREES.
The Sheriff does not have knowledge of recommendations to increase medical capabilities at the jail to a level that would support the care of certain intoxicated arrestees.
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.
Response:
Santa Cruz County Board of Supervisors PARTIALLY AGREES.
Netcom
has worked with county agencies in the past to develop management reports, but
is not currently working on such reports. The last statement on procedures is
correct.
Response: Santa Cruz County Sheriff's Office PARTIALLY AGREES.
Law enforcement officers use discretion when requesting an ambulance to the site of a public intoxication arrest based on observations at the site. In those cases in which an ambulance does respond to the site, there are occasions when the arrestee is evaluated but transported by law enforcement based on consensus between ambulance and law enforcement personnel.
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.
Response:
Santa Cruz County Board of Supervisors PARTIALLY AGREES.
Detention nursing
staff is not allowed to collect forensic evidence (Breathalyzer and blood/urine
evidence). Also, jail staff cannot
manage IV’s and patients who are not conscious.
Response: Santa Cruz County Sheriff's Office AGREES.
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.
Response:
Santa Cruz County Board of Supervisors NEITHER AGREES NOR DISAGREES.
The county has no
way of evaluating the accuracy of this finding.
Response: Santa Cruz County Sheriff's Office DISAGREES.
Law enforcement arrests and books those persons who are intoxicated but
not at risk for a health related problem and refers those persons who are
intoxicated and at risk to a hospital.
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.
Response:
Santa Cruz County Board of Supervisors PARTIALLY AGREES.
The previous
sobering center was closed due to a participant leaving the facility against
staff advice and creating serious problems in the neighborhood. However, the
sobering center was a voluntary program, so the terms “inmate” and “escaping”
are not accurate.
Response: Santa Cruz County Sheriff's Office PARTIALLY AGREES.
The sobriety center is no longer operational.
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.
Response: Santa Cruz County Board of Supervisors AGREES.
Response: Santa Cruz County Sheriff's Office AGREES.
The Sheriff has participated, and will continue to participate, in efforts to improve the delivery of incarceration and health services.
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.
Response: Santa Cruz County Board of Supervisors AGREES.
Response: Santa Cruz County Sheriff's Office AGREES.
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 to connect participants with outside agencies providing many services.
Response: Santa Cruz County Board of Supervisors AGREES.
Response: Santa Cruz County Sheriff's Office AGREES.
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.
Response: Santa Cruz County Board of Supervisors AGREES.
Response: Santa Cruz County Sheriff's Office AGREES.
The Sheriff supports all efforts to decrease the number of emergency room visits involving inebriates, but does not have specific knowledge of this program’s results.
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.
Response:
Santa Cruz County Board of Supervisors AGREES.
With the note that
the Superior Court is also participating.
Response: Santa Cruz County Sheriff's Office AGREES.
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.
Response:
Santa Cruz County Board of Supervisors PARTIALLY AGREES.
The county concurs
with detention personnel’s assessment that the program is working well.
However, program participants have several treatment options in addition to the
Janus detoxification program, including residential treatment at Janus, Santa
Cruz Residential Recovery, Hermanas, Si Se Puede, and New Life Center. In
addition, participants have outpatient counseling, day treatment, and clean and
sober housing available as continuing care options once they have completed
residential treatment.
Response: Santa Cruz County Sheriff's Office AGREES.
50. Under the Serial Inebriate Program, inebriates who are arrested three times go to detoxification or jail.
Response:
Santa Cruz County Board of Supervisors DISAGREES.
The criteria for
inclusion in the Serial Inebriate Program are being arrested, as well as
convicted five or more times in the last six months on 647f (drunk in public)
charges.
Response: Santa Cruz County Sheriff's Office AGREES.
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.
Response:
Santa Cruz County Board of Supervisors AGREES.
Response: Santa Cruz County Sheriff's Office AGREES.
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.
Response: Santa Cruz County Board of Supervisors AGREES.
Response: Santa Cruz County Sheriff's Office AGREES.
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]
Response: Santa Cruz County Board of Supervisors AGREES.
Response: Santa Cruz County Sheriff's Office AGREES.
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.
Response:
Santa Cruz County Board of Supervisors AGREES.
The county is
implementing this recommendation and has already had several meetings to
clarify billing options.
Response: Santa Cruz County Sheriff's Office AGREES.
This recommendation has been implemented. The Health Services Agency is primarily responsible for implementing
this recommendation.
2. Law enforcement officers should continue to receive training in policies and procedures for transporting serial inebriates to the emergency room.
Response:
Santa Cruz County Board of Supervisors AGREES.
The county is
implementing this recommendation and will offer more training through the
Chiefs’ Association.
Response: Santa Cruz County Sheriff's Office AGREES.
This recommendation has not yet been implemented but may be implemented in the future. Countywide law enforcement training managers will be contacted for participation in developing a training outline.
3. Detention staff and HSA should explore the possibility of establishing a sobering facility in Santa Cruz County.
Response:
Santa Cruz County Board of Supervisors PARTIALLY AGREES.
The county does
not plan to implement the recommendation at this time, primarily due to funding
constraints. However, the county is interested in establishing a sobering
center, provided that adequate funding and a suitable facility in a
non-residential area can be obtained.
Response: Santa Cruz County Sheriff's Office AGREES.
This recommendation will not be implemented because resources are not currently available. Additionally, any new detention facility would require California Department of Corrections and Rehabilitation's approval.
4. Project Connect is to be commended for its success in reducing Emergency Department visits, jail bookings and ambulance transports.
Response:
Santa Cruz County Board of Supervisors AGREES.
The county
appreciates and concurs with the Grand Jury’s commendation.
Response: Santa Cruz County Sheriff's Office AGREES.
The Sheriff's Office is a major stake holder in the Serial Inebriate Program.
5. County officials should join in efforts to maintain funding for promising programs that assist serial inebriates in creating stable lifestyles for themselves.
Response:
Santa Cruz County Board of Supervisors AGREES.
The county is
implementing this recommendation on an ongoing basis. Departments have
submitted recent grant applications to obtain funding for these services.
Response: Santa Cruz County Sheriff's Office AGREES.
This recommendation has been implemented. The Sheriff currently participates in the Serial Inebriate Program and other programs to address and mitigate chronic problems associated with inappropriate alcohol consumption.
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.
Response:
Santa Cruz County Board of Supervisors AGREES.
The county is
implementing this recommendation on an ongoing basis. County staff participate
in statewide alcohol and emergency medical services associations to accomplish
this goal.
Response: Santa Cruz County Sheriff's Office AGREES.
This recommendation has been implemented. Sheriff Tracy and HSA have
visited San Diego to observe their program.
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.
Response:
Santa Cruz County Board of Supervisors AGREES.
The county is
implementing this recommendation on an ongoing basis, involving Dominican and
Watsonville Hospitals via the Emergency Medical Services Commission, the Health
Improvement Partnership Council and other forums.
Response: Santa Cruz County Sheriff's Office AGREES.
This recommendation has been implemented.
Entity |
Findings |
Recommendations |
Respond Within |
|
Santa Cruz County Board of Supervisors |
1-53 |
1-7 |
60 Days (August 30, 2005) |
|
Santa Cruz County Health Services Agency |
1-53 |
1-7 |
90 Days (September 30, 2005) |
|
Santa Cruz County Sheriff |
1-53 |
1-7 |
60 Days (August 30, 2005) |
[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,
http://www.cms.hhs.gov/providers/emtala/default.asp.
[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, http://www.sandiego.gov/press/040914.shtml.