Title 25 involuntary hospitalization at Sheridan Memorial Hospital, hospitals across the state

SHERIDAN — Sheridan Memorial Hospital was not designed to accommodate people in mental health crisis. It does not operate an acute psychiatric unit; it does not offer — and is not designed to offer — inpatient psychiatric services. 
Despite this, SMH accepted approximately 150 patients held under Title 25 in 2021, hospital CEO Mike McCafferty said. 
Sheridan Memorial Hospital’s reception of patients held under Title 25 — and its role as the de facto inpatient psychiatric facility in Sheridan County — results in enormous staffing, security and financial burdens for the hospital, McCafferty said. 
When a law enforcement agency calls Sheridan Memorial Hospital to tell emergency room staff an involuntarily committed patient is on the way, hospital staff jump into action to make space in the hospital — space not designed to serve as an inpatient psychiatric facility — safe for a Title 25 patient. 
Staff roll away IV poles and supply carts and remove oxygen tubing and shower curtains, SMH Director of Critical Care Lynn Grady said. They take away any items not bolted to the walls or floors the patient might use to harm themself or others.
When the patient arrives, usually with a police officer or sheriff’s deputy, at Sheridan Memorial Hospital’s Emergency Department, the first step is medical stabilization, SMH Emergency Department Medical Director Dr. Luke Goddard said. Often, Goddard said patients arrive after attempting to hurt themselves, so the hospital treats physical injuries first. 
Patients are also sedated, Goddard said. 
Once the patient is medically stabilized, mental health evaluations begin, Goddard said. Within 24 hours of the imposition of the Title 25 hold, a social worker or psychiatrist evaluates the patient’s suicide and other mental health risks and reports back to SMH staff, explaining what level of mental health care would be appropriate for the patient. 
Would the patient be safe in an outpatient setting, receiving care from Northern Wyoming Mental Health Center, a counselor or an addiction medicine clinic? Or does he or she require additional inpatient care at SMH, the Sheridan Veterans Affairs Health Care System, Wyoming Behavioral Institute or elsewhere? 
If a mental health professional deems the patient safe to go home, that’s the end of it. No further care is required of SMH. In fact, if at any time the patient is no longer exhibiting suicidal ideations, a physician and nursing team will start developing a discharge plan, SMH Director of Quality Liz Mahoney said.
If not, SMH staff reach another decision point, Goddard said: Will the patient stay at SMH or be transferred elsewhere? 
SMH operates two safe rooms, intended for people — titled or otherwise — experiencing a mental health crisis and requiring stabilization, Mahoney said. The rooms are tiled and ligature free — or designed to ensure ropes and other materials cannot be tied to furniture or other fixtures — with beds bolted to the ground and an observation window. 
These rooms are not without their drawbacks, SMH Hospitalist Dr. Derek Gilbert said. Often, both safe rooms are occupied, and hospital staff and patients have to do the best they can with other rooms. The safe rooms are also centrally located right next to the nurses station to allow for easy access, but if psychiatric patients are loud, they can disrupt other patients’ healing. Finally, while in a psychiatric facility patients would live in a locked psychiatric ward with day rooms and space to move, Gilbert said patients in SMH’s safe rooms are confined to those rooms for safety reasons.

 
Although SMH’s emergency and hospital rooms are not designed to be converted into miniature acute psychiatric units, SMH’s facilities are nonetheless used to care for patients during Title 25 holds because Wyoming lacks adequate inpatient psychiatric beds, McCafferty said. 
Experts estimate states should have about 50 beds per 100,000 residents — meaning Wyoming should have nearly 300 inpatient beds. The state currently operates fewer than than 200 behavioral health beds. 
Wyoming also has the highest percentage — by 13% — of residents living in mental health provider shortage areas in the country. 
A 2021 report from the U.S. Health Resources and Services Administration and nonpartisan data analysis organization USAFacts found 96.4% of Wyomingites live in a mental health care provider shortage area, compared with 37% of people nationally.
None of this is good news for the state with the highest suicide rate in the U.S. According to the Centers for Disease Control and Prevention’s National Center for Health Statistics, Wyoming maintained the highest suicide rate in the nation since 2018, with the state’s suicide rate approaching 30 suicides per 100,000 residents in 2018, 2019 and 2020. 
This lack of care providers, hospital officials agreed, has dire consequences for individuals, Sheridan Memorial Hospital and beyond. 
At SMH, Title 25 patients have also necessitated additional staffing in some cases. 
McCafferty said the hospital hired a security team as a result of Title 25 holds. 
Although Goddard said Sheridan County law enforcement have been very helpful in staying with patients to ensure hospital safety, incidents sometimes happen, resulting in unsafe environments for SMH staff. 
Since 2017, SMH has added $1.1 million annually to its budget to enhance services and safety related to Title 25, McCafferty explained.
Throughout a titled patient’s time at SMH, a “one-to-one sitter,” or an SMH staff member tasked with supervising the patient at all times, is assigned to the patient’s bedside, Grady said. Although these sitters need not be licensed professionals — they can be certified nursing assistants — they nonetheless pose a significant cost to the hospital. 
One-to-one sitting responsibilities monopolize the employee’s time and energy, Grady said. For instance, a one-to-one sitter would be required to remain with one titled patient while a nurse would normally be expected to care for five to six patients. 
When SMH staff are injured while caring for a Title 25 patient, the hospital is also financially responsible for medical bills and time off related to those incidents, Grady added. 
This staffing pinch is exacerbated by the ongoing pressures of the COVID-19 pandemic. Health care providers are exhausted from treating repeated onslaughts of COVID patients — at times, having to treat double their average daily patient load — Grady said, but still have to care for behavioral health patients, which are also emotionally taxing. COVID has also exacerbated mental health issues for certain patients or required quarantining of behavioral health patients, Gilbert said. 
“It’s a circus, at times. It’s a rodeo,” Gilbert said of the competing challenges of COVID and Title 25. 
If SMH staff determine a titled patient requires additional inpatient care, the patient can be transferred to another facility. Titled patients cannot cross state lines under an involuntary hold, so any transfers must take place in Wyoming. But a dearth of inpatient psychiatric bed space across the state ensures SMH has few options for transferring patients in a timely manner. 
Goddard estimated SMH tries to transfer about 90% of patients needing inpatient care to Wyoming Behavioral Institute in Casper. 
However, WBI’s ability to accept new patients is often limited, Goddard said. The facility’s waiting list can be up to 20 patients and two to three days long, meaning transfers are unlikely to occur immediately. 
As a result, SMH sometimes sends patients to the inpatient psychiatric unit at Gillette’s Campbell County Memorial Hospital to await transfer to WBI, Mahoney said. In these cases, SMH is responsible for the costs associated with the transfer.
If applicable, SMH can also transfer patients to the Sheridan VA’s 20-bed inpatient psychiatric unit. If a veteran is determined to be a risk of imminent harm to themself or others and does not wish to enter inpatient care voluntarily, Sheridan VA practitioners can also start Title 25 hold processes, Sheridan VA Licensed Professional Mental Health Counselor Jennifer Fairbanks explained. However, the Sheridan VA facility is limited to veterans. 
McCafferty attributed slow transfer times to Wyoming's inadequate number of inpatient psychiatric beds as well as the lack of clinical expertise to provide adequate mental health services. Beyond the nearly 100 mental health beds Wyoming needs but does not have, there are too few psychiatrists, psychologists, therapists and other mental health professionals in the state to quench the growing need for care, McCafferty explained. 
“People aren’t getting the care they need in a timely fashion…and it leads to poor outcomes for people all across our state,” McCafferty said.
Between the provision of care for involuntarily committed patients, additional staffing expenses and costs associated with some of these transfers, Title 25 care represents an enormous cost for the hospital, SMH Chief Financial Officer Nathan Stutte said. 
By law, Sheridan County is responsible for costs associated with uninsured, titled patients’ care, Stutte said. The county, however, cannot foot that bill, so it made an arrangement to pay SMH an annual fee and allow the hospital to manage the finances from that point on. 
On average, Stutte said that flat fee covers 8 to 10 cents on the dollar for an uninsured, titled patient's care. 
Wendy Ongaro, executive director and primary care provider at One Health Sheridan (with which Sheridan Health Center merged in July), explained one way to help SMH and other medical care providers recover the enormous costs associated with Title 25 care is expanding Medicaid — a response Wyoming’s Legislature has considered and refused to pass each year since 2019 — and other social services to stabilize residents and preempt mental health crises. 
Many low-income Wyomingites live in a sort of limbo, earning too much to qualify for Medicaid and too little to be able to afford private insurance, Ongaro said. She estimated 23% of people struggling with mental illness in Wyoming fall into this uninsured category.
By expanding Medicaid eligibility, more Wyoming residents — including around 800 adults in Sheridan County — would be able to access the care they need, perhaps well ahead of a mental health crisis, Ongaro explained. 
The American Cancer Society’s Cancer Action Network recently estimated Medicaid expansion could offer care to about 24,000 Wyoming residents. 
Without drastic action, Wyoming risks the lives and dignity of thousands of Wyoming residents, Ongaro said. 
“In medicine, we think about the natural course of a disease…” Ongaro said. “This is sort of like the natural course of a community when there is no treatment available, when there is no intervention available.
 
This story was published on Sept. 20, 2022.