Riverbend: Early release poses danger

Last modified: Monday, August 08, 2011
Officials at Riverbend Community Mental Health say they are concerned the state hospital is discharging dangerous and unstable patients within hours of admission, possibly because of state budget cuts.

Louis Josephson, chief executive officer and president of Riverbend, sent a letter to state hospital officials six weeks ago expressing that concern, he said. Some of Riverbend's clients, one of whom suffered a gunshot wound to his chest during a suicide attempt, was released in less than 24 hours, Josephson said.

Josephson said his staff is also not being told of some of the patients being released early, which makes it difficult for staff to know when to follow up with a client.

'I know they are trying to do a good job and this is not about (blaming) them in any way,' Josephson said. 'But as we have been told informally, if you want people in the front door, you have got to get people out the back door. It's a dilemma for everybody.'

Josephson said hospital officials have not responded to his letter.

Dr. Robert MacLeod, chief executive officer of the state hospital, said he could not speak specifically about Riverbend's concerns but said the hospital does not base its discharge decisions on its budget or available bed space.

'We discharge appropriately,' MacLeod said. 'We treat each case individually. The connection between needing a bed and discharging a patient is simply not there.'

When MacLeod talked to the Monitor on Thursday, he said the hospital's 157 beds were not full. There have been only a few days when all beds were taken since the hospital eliminated some of its bed space in July, he said.

MacLeod said the hospital gets 2,450 admissions a year, with an average stay of about eight days. Two years ago, when the hospital had 210 beds, it had 2,300 admissions a year with an average stay of 10 days, officials said then. MacLeod said there are times when patients are released within hours of their arrival, but that is infrequent.

'I can tell you that at this hospital, irrespective of the number of beds we have, we are going to continue to discharge in an appropriate manner,' he said.

Officials at the state's other large community mental health centers could not be reached yesterday.

In Riverbend's letter to state hospital officials, Josephson said he gave several examples of 'rapid' discharges that concerned him. He declined to share the letter with the Monitor because it contained confidential information about clients.

'If they are (at the hospital) for less than 24 hours, you can barely do an assessment on them,' Josephson said.

He said Riverbend's concern involves clients who are admitted against their agreement because they need help but won't accept hospitalization voluntarily. Those people are brought first to the Concord Hospital emergency room for a psychiatric evaluation. If they have been using alcohol or drugs, they are held until they are sober and are then evaluated.

Riverbend's staff recommends involuntary commitment only when releasing someone would pose a danger to the person or others, Josephson said.

'Someone who needs involuntary commitment by definition has real safety concerns,' Josephson said. 'They are either homicidal or suicidal.'

In one case, Riverbend had a client in its adult program admitted because of safety concerns, Josephson said. Staff were surprised and concerned when the person arrived back at Riverbend the next morning, especially since they had not been told the person was released, he said.

Had the person not returned to Riverbend the day after release, staff would not have known to follow up with a safety check, he said.

Josephson said staff learned second-hand that a suicidal client who had shot himself had been released within 24 hours. They called the police and asked an officer to visit the man and do a safety check.

'I guess you can say someone gets to the hospital and they say they are fine,' Josephson said. 'But in our field, the best predictor of future violence is a history of past violence.'

There are times, MacLeod said, that a person must wait in the emergency room for one, two or more days waiting for a bed to become free at the hospital. During that wait, the person may get medication or counseling that makes him safe enough to return to the community without ever entering the state hospital.

Releasing a person in that case is not motivated by budget concerns, MacLeod said. The person has instead become safe enough to discharge.

MacLeod said the state hospital does notify the community mental health center when one of its clients is released. MacLeod said the center must sign off on the discharge if someone is being discharged with conditions. For other releases, the hospital 'makes every effort' to connect the patient with the mental health center.

He said there have been cases where 'the communication was not as good as it could have been,' but he said he believes the system is working well overall.

Josephson said Riverbend respects the hospital's work and understands that different doctors may come to different conclusions about when a patient is ready for discharge. And while he doesn't believe the state hospital doctors are trying to do anything harmful, he fears 'rapid' discharges can be very dangerous.

'I think some cases are really high risk and that there is a lot of pressure at the front door (to take new patients),' he said. 'Our job is to keep the people safe and keep the community safe, and that is what we are trying to do. I know they are trying to do a good job, too. I think they are between a rock and a hard place.'