Contracting Out MH Transportation Not Best Choice

The Richmond Times-Dispatch has a front-page article today that raises many questions. It reports that the Department of Behavioral Health and Developmental  Services (DBHDS) has entered into a two-year, $7 million contract with a private company to transport persons, who have been temporarily detained, to hospitals or mental health facilities for evaluation of being involuntarily committed.

Traditionally, sheriffs’ deputies or police officers transported these individuals, usually in marked police cars and sometimes in handcuffs. The rationale for contracting out this service is that it will be less traumatic for the involuntarily committed person and it will free up law enforcement officers, who spend thousands of hours on these transportation runs, for other public safety functions.

I sympathize with the motives for the change. Putting mentally ill people in police cars, sometimes in handcuffs, undoubtedly increases their trauma and reinforces the stigma accompanying mental illness. Law enforcement officers often have to drive many miles, sometimes across the state, to transport these patients, wait until the mental health facility accepts them as patients, and turn around and drive back to their home locality. That is a lot of time that the officers could have been on patrol duty, enforcing traffic laws or responding to calls for law enforcement support.

Nevertheless, contracting out this function to a private company is not necessarily a good idea.As the term implies, persons being involuntary committed usually do not want to go where they are being taken. It takes special training to manage someone in a mental health crisis who is being forced to do something he/she does not want to do. The person can become violent, threatening injury to the person doing the transporting, or, probably more likely, injuring himself or herself. Of course, the company with which DBHDS will contract with promises to train its drivers “on behavioral health services, supporting and supervising people in a crisis, and human rights and crisis intervention.”

This raises several  questions: Will DBHDS set the standards for this training? If so, to what extent will DBHDS monitor the training and the conduct of the contracted drivers to ensure that those standards will be met? What is the legal authority for a private contractor to constrain a person who is being transported to an involuntary commitment evaluation?

As a private business, the contracting company will seek to minimize its expenses as much as possible in order to maximize its profits. Therefore, it will tend to hire drivers at the lowest end of the salary scale and it will probably offer few benefits, such as health care and retirement. The result will be a high turnover of drivers, who are minimally experienced and trained.

State agencies contract out service delivery for a variety of reasons. Sometimes, but not always, it is cheaper. Sometimes, it is easier to delegate the administrative burden of recruiting and training employees to a private company. Regardless of the reasons or benefits of contracting out a service, a state agency loses some measure of control over the delivery of that service, although it is still accountable for it. For some services, it may make sense for a government to contract out a service. Building a road or bridge is a good example. But, for a sensitive service such as transporting a person in a mental health crisis, it would probably be better for the agency to use personnel who are accountable to it, rather than to a third-party contractor.

A better way to relieve the pressure on sheriffs’ offices would have been to provide additional funding to each office to hire one or more additional transportation officers. Those offices already have experience in transporting persons in a mental health crisis. To relieve the trauma and stigma associated with being transported by law enforcement, the officers could use unmarked cars and wear civilian clothes rather than a uniform. When they were not being used to transport patients, those additional officers could be engaged in regular law enforcement duties.

Finally, as a budget analyst, I would ask: How did DBHDS come up with an additional $3.5 million per year for this contract? Does the agency have that sort of extra money sitting in its appropriation, unneeded, or is something else being cut?

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7 responses to “Contracting Out MH Transportation Not Best Choice”

  1. There’s no mention of a bigger problem — the lack of mental facilities within reasonable distances of localities. That lack requires enormous amounts of law enforcement time to transport and escort disturbed persons.

    At our April Mathews County Board of Supervisors meeting, our sheriff described a recent situation. After a deputy was in court most of the day, a call came in at 3 p.m. to take a person into temporary custody and transport him to the local hospital for mental evaluation. After a lengthy process, a full time deputy and part time deputy were then sent to transport the person to a mental facility in Staunton, VA. They did not get back until 6 a.m. the next day. This is a hardship on a mentally ill person and for a small sheriff’s department to provide coverage in the county, and the county gets to absorb the overtime costs. I’d be surprised if there is any accounting of all the time and expense involved for our localities.

    1. Dick Hall-Sizemore Avatar
      Dick Hall-Sizemore

      Thanks for the specific example. It illustrates the problem well.

      You mentioned the lack of mental health facilities within reasonable distance of localities. There is actually a second problem–a shortage of beds. The first problem is not applicable to Mathews County. There are two major state mental health facilities within reasonable of you: one in Williamsburg and one in Petersburg. The fact that the Mathews deputies had to go all the way to Staunton to transport the patient was, I suspect, a result of the unavailabilty of a bed at either Eastern State or Central State or at any private facility on that particular day. Localities in Southwest Virginia have to contend with both problems.

      The broad questions of how many beds and their type (community or residential) are needed are thorny ones and are being grappled with by the General Assembly.

  2. LarrytheG Avatar

    Yeah, I’m with Cbova on this one. This is an example of penny-wise and pound-foolish and it’s driven by a mentality that mental health on the public dime is “expensive” and we need to cut it to the bone and as a result we have terrible overcrowding in the existing hospitals which then results in having to drive to a facility that has a bed.

    Creigh Deeds had a tragedy in his own family as a direct result of this problem.

    I’m ashamed of how Virginia deals with this issue.

    1. Dick Hall-Sizemore Avatar
      Dick Hall-Sizemore

      The delivery of mental health services is a knotty issue. It is not primarily a case of the Commonwealth cutting the funding “to the bone”. The major issue is how services should be delivered. About 50 years ago, there was a movement to shift services from central institutions to care in the community. There was a lot of justification in this argument; many people committed to the “insane asylums” did not belong there and some of those facilities were real hell holes.

      About ten years ago, the federal Dept. of Justice, in a continuation of this movement toward community care, sued Virginia over condition in the mental health facilities. As a result of the consent agreement, the state increased its closure and consolidation of mental health facilities.

      There are a couple of problems with the shifting of the emphasis to community care. Although the Commonwealth has provided a substantial amount of funding for community care, an adequate network of community residential facilities, both inpatient and outpatient, has not been developed. Unfortunately, some people need residential care. As a result, a significant number of people with serious mental health issues are “on the street.” Many end up in jails (a subject of a later post).

      The Deeds Commission has brought new attention to all these issues. As a result of this awareness and the adoption of its recommendations, more people are being referred to the state mental health facilities for evaluation. The inevitable result has been a squeeze on the availability of beds. The 2019 GA approved the replacement of Central State Hospital in Petersburg, although with fewer beds than DBHDS had proposed. There is language in the Appropriation Act for the department to study the “right-sizing” of the system and report to the GA this fall on its recommendations. In summary, the problems are known, but the solutions have not yet been agreed upon.

  3. There’s nothing wrong with outsourcing a service like transportation of MH patients — as long as the key performance criteria are spelled out and carefully monitored, and the contractors are held strictly accountable. Unfortunately, many government agencies figure that once they outsource a function, they don’t need to worry about it anymore.

    1. LarrytheG Avatar

      I’m okay with outsourcing per explicit performance agreement but also the employes need to be qualified. Replacing qualified folks with cheaper unqualified folks is dumb and pound foolish and in this case – it appears the whole problem is not enough space in the system so they transport folks to other facilities that do have space. This is a bigger problem than just “outsourcing” – they’re underfunding a basic function and in doing so – they’re endangering patients and increasing transport costs – and they’re trying to “save” on those transport costs.

  4. Jim Loving Avatar
    Jim Loving

    I read the RTD article, Creigh Deeds and the National Alliance for Mental Illness endorse this contract and approach.

    I am familiar with the Temporary Detention Order (TDO or Green Warrant) process in VA, having been involved with one over 15 times in Henrico. I am also familiar with the Police training in Crisis Intervention Team Training (CIT), which is key for all police to receive.

    Before this contract, the way a TDO usually happens is this: The PD can do a health check with/without the local Mental Health board (usually in coordination with) and then the TDO process can be initiated and the PD apprehends the person and takes them to a temporary facility (Parham road in Henrico) where they are further assessed then if it is determined they are to be hospitalized, a bed is searched for, and they are transported to the hospital.

    From reading the RTD article, it sounds as if the contractor will transport from the check-in facility, and not be involved in the initial apprehension. Unless the contractor had CIT training and was experienced at de-escalating a situation and apprehending a non-compliant person, I do not believe they would transport from pick-up to check-in, only from check-in to hospital (I intend to investigate this more).

    If that is the case, then I do not see anything wrong with the logic behind outsourcing this transport function. The Sheriff/PD would not have to transport the patient at that point, after initial pick-up. If, however, this contractor is now going to do initial apprehension, then I think this would be a big issue.

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