The state of Vermont is renewing efforts to decrease the use of restraints on mentally ill residents who are involuntarily put in state care.
State law – passed in 2003 and updated in 2005 – declares that residents should be transported with “the least restrictive means necessary.” Despite the law, data compiled by the Department of Mental Health shows that the use of metal restraints is static. They were used for involuntary transport of adults 58 percent of the time in 2011 (59 percent in 2010).
For “secure” transports (transporting by uniformed sheriff’s services), metal restraints were used 73 percent of the time, up from the previous two years. In the one-year period ending in November 2011, 51 percent of involuntary transports were secure transports.
Some mental health workers say that while DMH has given the mandate to transport by less-restrictive means – the department has neither the resources nor authority to enforce it, since the issue of involuntary transfer from hospitals includes federal regulations and regulations of local hospitals, ambulance companies, and sheriff’s departments.
Jeff McKee, Psy.D., director of psychiatric services at the Rutland Regional Medical Center, says the solutions can come from local collaborations.
“Here in Rutland, we looked at some other areas of the state that were doing it well… Bennington in particular,” McKee says. “We got together with our local sheriff’s department and our regional ambulance service and really talked about what our community needs.”
“In Rutland, there have just been a tiny, tiny handful of folks who have had to go with restraints in the past couple of years,” McKee says. In fact, since 2006, hospital policy states that ambulance is the appropriate transport for acute care patients regardless of diagnosis. “We treat psychiatric patients like we would any other patient in the hospital,” McKee says. “It’s done in the least restrictive manner possible.”
McKee notes despite some initial trepidations from the agencies involved, “We decided that we had thought it through well enough that we just needed to start trying it and trust that people could manage it, and it’s turned out very well.”
“It’s not a financial hardship, and there don’t seem to be many barriers once people come together and agree that’s what needs to be done,” he said. “It does require folks to come together with the same level of concern of what the care has to be.”
DMH Deputy Commissioner Mary D. Moulton, MPA, says the state is working hard to encourage such collaborations.
“As a state we need to look throughout the region and see how everyone is managing transports and then meet with ambulance companies, the sheriff’s departments, the ER and community mental health centers and talk about how it’s currently being done and how we can make a change toward having an avenue toward least restrictive transports,” Moulton says.
“They are all private entities – the hospitals are private, the agencies are private, the sheriff’s departments are private and the ambulance companies are private or volunteer,” Moulton says. “We have to rely on their willingness to work with us and I have to say there’s a tremendous amount of cooperation right now on all of those entities to come together and talk to us.”
Moulton has been meeting with these parties throughout the state, trying to come up with a standardized and better-informed system. “I am creating alternatives as fast as I can, and I have to say the agencies are very involved in discussions,” she says.
The DMH created a transportation work group and is revising a transport assessment checklist. Moulton says one sheriff’s department has already developed a policy to enforce the use of soft restraints (introduced in the state in 2009 as an alternative) and other departments have ordered them.
Additionally, sheriff’s departments are asking to take enhanced mental health crisis training that the state is rolling out and one sheriff’s department has expressed a willingness to create an alternative transport team as a pilot project, with sheriff’s wearing plain clothes and driving in unmarked vehicles.
McKee says patients seeking treatment are often scared and confused and the use of shackles and restraints can exacerbate conditions. By transferring people without restraints, “You don’t damage the trust that you’ve established with the patient.
“You’re really honoring them and doing it in a way that’s supportive and caring. It really sets up the next level of care to start off on a much better footing.”