It was the most hopeful Sandy Sharp had felt in a long time.
Her 29-year-old son, Drew, had landed a bed at Grant House, a residential treatment facility in Denver. He was on track to stay there for a year. It seemed to be a huge breakthrough for Drew, whose schizophrenia and substance use had set him on a decade-long path of forced hospitalizations, homelessness and cycles in and out of jail.
But the following week, the Monday after Christmas, Sharp got a call that Drew had walked away from the facility and was missing. With dozens more troubled Coloradans in line, her son had lost his bed. She eventually learned he was at the ER, and after about a week at a short-term facility for the unhoused, he was released back to the streets.
And with that, there he was again: living on the street and 44th on a waiting list for a short-term mental health bed.
One way Sharp has tried, more than 30 times, to get help for her son is through a 72-hour involuntary hospitalization. But if involuntary holds are meant to be a starting point for people with serious illness to get care, they rarely give Drew the kind of steady help he needs.
Now state lawmakers and advocates want to change how involuntary holds work for people with the toughest cases.
A bill that will be introduced at the state legislature this year, and which was spearheaded by the advocacy group Mental Health Colorado, aims to give people greater protections as they undergo involuntary care, including through access to a state-funded attorney or the ability to appoint a trusted person as their representative. It would also require the state’s new Behavioral Health Administration to take a more central role in the civil commitment process rather than leaving individual providers — of which there simply aren’t enough — to figure it out for themselves.
The goal of the legislation is to ensure people continue to receive care after they’ve been released from an involuntary hold and that patients also have choices as they go through the process, said state Rep. Judy Amabile. The Boulder Democrat will be a prime sponsor of the bill when it’s introduced later this year.
“I think this bill is getting set up to help us move in a better direction,” said Amabile, who is the parent of an adult child with severe mental illness.
The proposal is still in its early stages, and will certainly change as it is debated by lawmakers and interest groups. And even if it passes, the question is whether lawmakers will put enough funding into the system that supports people with serious mental illness.
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State lawmakers this year have a big, one-time opportunity to spend nearly $2.6 billion in remaining federal stimulus dollars, at least $550 million which is set aside for behavioral health needs. Over the next few months, legislators will debate how to best spend the money on a host of needs across the state, from an ongoing opioid crisis to the shortage of youth and adult mental health crisis beds.
Sharp, along with a number of other parents and relatives of people with serious mental illness, believes the biggest investment should go toward new mental health beds. Changing rules about involuntary holds won’t really matter unless there’s a place for people to go, she said.
“The improvement that he was showing at these places was enormous,” said Sharp, who spends hours driving up and down Colfax Avenue or on the phone with shelters trying to track down her son and get him into care. “But they each have their own term limitation, and we just don’t have enough beds.”
A shortage of beds and resources has ripple effects
Colorado law allows people to be taken to a facility for involuntary care for up to 72 hours if they’re deemed an “imminent risk” to themselves or others. A person who is “gravely disabled” and lacks the capacity to care for themselves – like a person found wandering in freezing weather without clothes, or who can’t feed themselves – can also be put under a hold.
The hold is meant to be temporary, an opportunity to help people get access to medication and stabilize. Most people are released before the end of or after the three-day period, unless a professional clinician decides and can prove in court that a person would benefit from further involuntary care under what’s known as a certification or civil commitment.
More than 32,600 involuntary holds, known as M1 holds, were placed in Colorado in 2019, the most recent data available. And those holds turned into short-term certifications, up to 30 days of treatment, in 6,587 instances. More than 600 long-term certifications were initiated that year.
The bill being brought by Amabile would update a law that has been largely untouched since it was enacted 50 years ago, said Lauren Snyder, the vice president of government affairs for Mental Health Colorado and who has spearheaded the effort.
The current law was written for a time when beds were more available and institutionalization was the norm for people with serious mental illness. Now with a shortage of beds and long wait lists, most people receive care through outpatient facilities rather than staying in a closed, locked building.
And there’s not much infrastructure to ensure people have a relationship with their doctor, show up for medication appointments and have basic resources like transportation or housing.
“As a provider, I’m responsible for this person, but I can’t (help) because the system can’t help me access them,” said Dr. Fred Michel, chief medical officer at SummitStone Health Partners in Larimer County.
The law has no language governing outpatient care, except a single line allowing people to receive care on an outpatient basis. The bill would try to address that by outlining new standards for people receiving involuntary care but who aren’t housed at a facility.
“So much of behavioral health is having a relationship with someone, and if that’s disrupted every time, it’s difficult,” said Michel, adding that it’s emotionally exhausting for patients to open up to a new doctor turn after turn. “If you had surgery and you were seen by a new person every day, it gets confusing to even know what the plan would be potentially.”
The statehouse proposal would also require the new Behavioral Health Administration — an agency created by lawmakers last year — to work with providers to develop a treatment plan, create a grievance process and allow a person or their representative to contest treatment plans at court hearings.
It also aims to make sure that people can get a lawyer when they’re facing a potential certification, not just when they’ve already been put under an involuntary commitment.
“People lose a lot of credibility to what they’re saying as soon as they’re certified. And that’s a terrifying place to be as a human being, ‘nobody listens to me,’” Snyder said.
The bill would also:
- Clarify limits on how long a person can wait to be evaluated for an involuntary hold or certification, to prevent people from languishing in isolation
- Add language allowing people to appoint a layperson, such as a relative, as their representative and file grievances or contest a treatment plan
- Require providers to reach out to a person before asking law enforcement to intervene
- Add new requirements for discharge plans, like providing necessary medication and follow up
- Require the state Judicial Department pay for an attorney for all people under certification, not just low-income people
- Allow people, particularly people in jails, to petition the court directly for a civil commitment, without having to undergo a 72-hour-hold
Right now, the state doesn’t track or monitor people who are placed under a hold or certification. It’s up to hospitals, community mental health centers and other facilities to set up discharge plans and link a patient up to further resources.
But many counties don’t have enough providers and support to make outpatient care work, said Karen Rice, assistant medical director for Mental Health Partners in Boulder County. Both Michel and Rice work with programs that do outreach and intensive care for people with severe, persistent mental illness.
That involves a whole team of doctors, social workers, law enforcement or co-responders who work together to proactively check on patients, including visiting people at their homes or at the shelter or the public park where they are living. That kind of support can also build trust that prevents a hold from being used in the first place, Rice said.
“You have to engage the patient on a very regular basis, at least once a week, probably multiple times a week,” Rice said. “If they don’t show up for their injectable medication, do I even hear about it?”
But many communities don’t have such programs. Some hospitals can work hard to put together a patient’s discharge plan, but if they can’t find a facility with the capacity to accept responsibility for a patient, or local law enforcement are unwilling to participate in involuntary holds, a certification can be dropped entirely — meaning no one is following up with that person.
“The main reason that people don’t accept certifications is because they don’t have the team they need across the community to make them work,” Rice said.
Michel said the bill could help address that by making the BHA responsible for follow-up, so a person doesn’t just fall through the cracks.
Rice, as well as advocacy groups and other providers, also say it’s become more difficult in recent years to get police involved in involuntary holds.
Law enforcement groups have been engaged in talks about the policy proposal since last year. They declined to comment on the bill because it’s still a draft, but cited concerns about recent police reform legislation that ended qualified immunity for officers, creating “increased personal liability that officers now face when engaging in these situations.”
“We recognize that our state needs better tools to address mental health crises and will continue to advocate for the expansion of prevention services and building of community resources to intervene in mental health situations to keep individuals, families and the public safe during a crisis,” according to a joint statement from the County Sheriffs of Colorado, Colorado Association of Chiefs of Police and Colorado Fraternal Order of Police.
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Hospital groups also cited concerns about new requirements for discharge plans in the proposal. There are plenty of laws requiring hospitals to come up with detailed discharge plans, said Joshua Ewing, a lobbyist for the Colorado Hospital Association.
“It’s not to say that discharge planning or patient’s rights aren’t important. But it’s impossible to do discharge planning if you have nowhere to send someone,” Ewing said.
Difficult choices about when to force care
Lawmakers and mental health advocates have also weighed whether the standard for who can be placed on a hold should be lowered or changed.
In 2018, lawmakers discussed whether to change the “imminent” risk standard during debate over a “red flag” law that allows judges to order the temporary removal of guns from people who pose a safety risk.
But both Republicans and Democrats expressed concerns that changing the standard would harm patients’ rights.
A separate bill slated for introduction this year aims to make it easier for people to be placed under a hold, by requiring a person to be a “substantial” rather than “imminent” risk.
It’s not clear whether that bill will move forward. Mental Health Colorado opposes it, arguing reform should focus on the process once a hold is initiated.
State Rep. Adrienne Benavidez, one of the prospective bill’s prime sponsors, said she’s not sure it’s the right solution, but the current standard clearly leaves many people behind. “I’ll push the bill so the legislators will be able to weigh in on it,” said Benavidez, a Commerce City Democrat.
Psychiatrists and providers also have a difficult balance to strike. Rice, the assistant medical director at Mental Health Partners, is guarded against any changes that might erode a patient’s choices.
Involuntary holds should always be a last resort, she said. Forcing someone to undergo treatment is a negotiation between allowing them to make choices about their body, get the treatment they need, and preserving the relationships that will make it all happen.
Rice recalls a patient under a certification for an extended period who had been released from the hospital and was doing well.
“He said he would stop taking his medications after treatment. I know he’s going to stop taking meds, but on the other hand, he’s doing well … they deserve a shot to succeed or fail on their own,” Rice said. “And there are going to be patients that, no matter what happens, they aren’t going to have insight into their mental illness.”
Building trust also impacts a patient’s wellbeing and ability to engage with care, especially for patients who experience psychosis and distrust of others.
“A lot of these people become psychotic for the first time and they’re 22 (years old). We don’t know the trajectory of their illness, nor do we even know what the exact diagnosis is,” Rice said. “What could possibly be worse than completely alienating this person from the mental health system?”
Waiting for the next placement
Since his first psychotic break at age 19, Drew has been on dozens of holds. Many times, Sharp has called 911 and been told by police or hospital staff that he doesn’t need to be hospitalized involuntarily. Other times, he’s been hospitalized but there’s no place for him to go once the hold ends.
He’s attempted suicide. His voices often urge him to beat his mother, making it dangerous for her to be around him. Even during periods when Drew has been able to work and live alone in an apartment, she’s found him at home with the gas burners on his stove turned on or wandering the streets in freezing weather.
“Even if you have a place that can hold him for three days, they’re kicking people out as fast as possible because other people are waiting,” Sharp said.
But on Tuesday, she got a glimmer of hope: a call from Drew.
He had been homeless, using methamphetamine and had frostbite on his feet. He walked to a crisis center and was able to get admitted to the Denver Solutions Center, where he will be able to stay for 30 days, detox and be supervised on medication.
Drew said he doesn’t want to be homeless anymore. And Sharp has seen him improve at the Solutions Center before.
But there’s still that waitlist to consider.
“I am not sure if he will move up enough on the waitlist to be referred to a mental health bed after his 30 days,” Sharp said. “Each time he goes back out, his low is lower … he gets closer to not making it — to death.”