As the number of online beds and employees working at the Colorado Mental Health Institute at Pueblo continue on a downward trajectory, triage measures to help alleviate the increasingly clogged pipeline for pre-trial criminal defendants waiting in jails for admittance to Colorado's largest psychiatric hospital are underway.
“We’re using a system that doesn’t work now,” said Ray Merenstein, executive director of the Colorado office of NAMI, the National Alliance on Mental Illness.
“It’s not a crime to have a mental illness, (but) we have a system in place to encourage almost criminalizing mental health — we’re going to put you in jail, and when you get out, we still don’t have anything for you,” he said.
Various problems at the Pueblo mental hospital contributed to Colorado ranking worst of the nation's 49 other states and the District of Columbia for adults with a higher prevalence of mental illness and lower rates of access to care in Mental Health America’s newly released scorecard, Merenstein said.
“It all ties back to the bed issue and people still in jails and not getting the competency assessments they need, and the state paying fines,” he said.
The state-run forensic psychiatric hospital in Pueblo, which determines whether people accused of committing a crime are mentally competent to stand trial and works to restore competency, is licensed for 516 beds.
Current occupancy is 394, according to Madlynn Ruble, spokeswoman for the Colorado Department of Human Services, which oversees the facility in Pueblo and a mental hospital for civilians in Fort Logan.
That’s down from a mid-September census of 416 occupied beds at Pueblo.
Staffing shortages combined with recently mandated suicide mitigation improvements have led to temporary closures of two admissions units, one cognitive behavioral unit, half of a restoration unit and half of an adolescent unit, Ruble said.
The Pueblo hospital has 1,120 state employees on the campus, she said. That’s a decrease from 1,147 in mid-September. There are also 135 contract nurses, psychiatric, medical and other staff on site, down by a handful from earlier this fall.
Meanwhile, the state's waiting list of inmates court-ordered to receive psychiatric evaluation or restoration, which had hit a low of 52 in August 2020, reached a record high of 349 on Nov. 1, state documents show.
The coronavirus pandemic caused “significant delays in admissions” to the Pueblo hospital, state officials said, because of virus prevention strategies that included a cohort admissions process, which requires incoming patients to undergo a 14-day monitoring period before being admitted to inpatient units.
Four major COVID-19 outbreaks at the Pueblo hospital last year and this year, infecting a total of 465 staff and patients, according to state data, and outbreaks in jails around the state further slowed intake, officials said.
Now, work has begun to address violations of safety measures and protocols that state regulators uncovered following a suicide attempt inside the Pueblo hospital in July that left a 20-year-old patient with brain impairment.
Federal regulators threatened to stop paying Medicare claims by Dec. 14, if suicide risks are not mitigated through environmental and physical changes at the facility.
The General Assembly’s Joint Budget Committee in late September approved an emergency supplemental budget request of $4.1 million to bring the hospital into compliance with federal standards.
The treatment provision and suicide mitigation are requirements of the Centers for Medicare & Medicaid, the Colorado Department of Public Health and Environment, which conducts state investigations at the facility, and the Joint Commission.
The Department of Human Services has hired a company to add more surveillance cameras in patient hallways in seven buildings, Ruble said, and is seeking a technical architectural firm to help design, test and determine upgrades needed for doors. Chase Falk's attempted suicide earlier this year was done by hanging from his door with extra sheets, according to a Centers for Medicare & Medicaid report.
Ligature-resistant doorknobs will be installed, continuous hinges will replace three-point hinges, corridor door closures will be upgraded, and the tops of doors in patient rooms will be angled to eliminate a pinch point at the top.
In three units, existing grid ceilings will be replaced by hard ceilings.
New equipment will improve follow-ups on incidents and investigations, and human services will implement a new system to “provide the appropriate departments and leadership with complete incident information, as well as aggregate information to identify trends and areas for improvement,” Ruble said.
If state lawmakers approve another capital request from the human services department for an additional $5.1 million in the state’s 2022-23 budget — part of the record $40 billion Gov. Jared Polis submitted last week to the Joint Budget Committee — upgrading bathroom fixtures and further suicide mitigation would be done, Ruble said.
The projects could take up to 18 months, she said, which state regulators said in a recent report could further stall admissions of inmates at the Pueblo hospital.
Also included in Polis’ proposed budget is $10.4 million to hire 100 staff to open and operate 44 new forensic beds at the Colorado Mental Health Institute in Fort Logan. If approved, the beds would be available in the fall of 2022, Ruble said.
That state-run psychiatric hospital normally only treats civil patients.
Polis also recently earmarked $20.26 million from American Rescue Plan federal pandemic-recovery funds to help expedite evaluation and restoration services.
Most of the money, $19.74 million, will pay for a contract for 64 private hospital beds over the next year to serve about 150 people.
Remaining relief funds will be spent on medication-prescribing services for inmates waiting in jails across the state and for community housing with case management for 40 people in the system.
“The Office of Behavioral Health is using all of the tools at our disposal to address the waitlist for inpatient competency services,” Ruble said.
Fines fund projects to lessen jail backlog
Fines the state Department of Human Services has paid for violating a 2019 federal consent decree — emanating from a lengthy lawsuit from Disability Law Colorado claiming the state was violating due process in evaluating and treating mentally ill criminal defendants in an untimely manner — continue to mount.
The state has been fined more than $24.5 million, according to documents, with a $10 million annual cap. During some months of the pandemic, fines were reduced to zero in recognition of the special circumstances beyond the state’s control.
The department has paid out roughly $17 million of the levied fines, Ruble said, with accruing fines to be disbursed next June.
Those receiving funding from the fines include Denver Health and Hospital Authority, which just completed a $2.74 million contract to lease five “transition” beds for patients needing psychiatric competency restoration, from June 2020 to October 2021.
“These beds have been fully utilized throughout the duration of the contract,” a Denver Health spokesperson said in an email, calling the program “hugely successful.”
Another $749,000 is funding 12 of the 48 beds in the Men’s Mental Health Transition Unit at the Denver County Jail for services for pre-trial defendants in the jail or Denver’s Downtown Detention Center.
The pilot program began May 10 and will run through April 2022.
“The goal is to decrease the amount of time an individual is in jail awaiting competency restoration services, while also ensuring individuals who are restored to competency remain restored until their court proceedings,” Daria Serna, spokeswoman for the Denver Sheriff Department, said in an email.
From August 2020 to January 2021, 169 out of 195 court orders in Denver’s 2nd Judicial District were issued for inmates found incompetent to proceed to trial, she said.
“These individuals cannot move forward with their case until they are restored to competency, often extending their length of stay in the jail,” Serna said.
Program participants receive competency education, treatment planning, individual and group therapy, psychiatric services, and transition and re-entry planning, she said.
Denver County Sheriff Elias Diggins has publicly referred to his jail as the second-largest mental health facility in Colorado, next to the Pueblo hospital.
The pilot program is modeled after Arapahoe County Jail’s RISE, or Restoring Individuals Safely and Effectively, program, which began in 2013. It's based on a national model and uses a team of specialists who come into jails to help inmates needing treatment be restored to mental competency usually within 60 days.
Community-based programs could help
Colorado’s backlog of mentally ill criminal defendants also would decrease if instead of being kept in custody, those facing minor misdemeanor charges could be diverted out of the criminal justice system and sent to community-based programs for treatment, some believe.
“If there was accessible treatment and appropriate housing for those with serious mental illness, many wouldn't wind up in our jails and prisons,” said Lori Jarvis-Steinwert, executive director of the NAMI office in Colorado Springs.
“And when you think about it, the last place you want someone dealing with serious mental illness is incarcerated or in the county jail.”
To complicate matters, inmates in line often are considered a risk to themselves or others while in jail, so they’re placed in isolation, Jarvis-Steinwert noted.
“That only intensifies their illness,” she said.
At least two people waiting in jails for a psychiatric bed have died by suicide this year, according to the state Department of Human Services.
Ideally, Jarvis-Steinwert said, people would be placed in residential programs designed to address their needs with counseling, medication management, occupational and recreational therapy and social activities.
Those types of settings, however, are “very limited,” Jarvis-Steinwert said.
NAMI Colorado's Merenstein said increasing the number of forensic beds without increasing civil beds “leaves a lot of people standing out on the street or going back to jail,” he said.
The national standard is 50 psychiatric beds per every 100,000 residents, he said, and Colorado has fewer than 10 beds per 100,000.
“Four out of every five people are still waiting for a psychiatric bed in Colorado,” Merenstein said.
Ideas being floated are turning empty city or county buildings or old group homes into small, inexpensive pop-up units of 15 beds or less, he said.
A group of mental health advocates including Merenstein are petitioning Colorado’s Behavioral Health Task Force and the Affordable Housing Transformational Task Force for $165 million in COVID recovery money for more beds as well as sober-living housing, respite homes and other accommodations for people transitioning out of inpatient care.
“We need 196 new residential beds statewide and 64 more civil inpatient beds,” Merenstein said.
Money also is needed for the workforce, he said, to not only add employees but also train and pay them well enough so that they want to stay.
“We can use these one-time housing and behavioral health dollars to really push getting the system in place,” Merenstein said.
“The more you stabilize an individual or give them a safe setting, the more likely they are to be on the road to recovery. That’s been the problem all along.”