Checks and balances govern the process for committing those who are dangerous to themselves or others to the state-run Community Behavioral Health Hospital in Wadena, according to social services staff.
Mental Health Case Manager Todd Anderson provided an overview of the commitment process to the social services board at its March meeting.
It is a very condensed version of the process, said Lori Miller, adult services supervisor. "In reality [it's] a very lengthy process with several checks and balances along the way," she said. "As it very well should be, because we're making a very serious decision about someone's life."
The process usually begins at the emergency room and involves temporary holds, psychiatric evaluations, social worker involvement and court hearings before a commitment is established.
Law enforcement or family or friends who believe a person isn't stable transport him or her to the emergency room,
"If that doctor feels that they're presenting a danger either to themselves or to others by behaviors or statements that they're making, that ER doctor can sign what they call a 72-hour or emergency hold," Anderson said.
The hold allows for further testing and evaluations to make sure the person stabilizes or gets needed services if they will not voluntarily do so, he said.
Emergency room staff calls a central intake office, the state-run facility that accepts people to CBHHs, he said. The office tries to find a CBHH with an open bed that is near where the person lives.
"So if they're from the Wadena area they will try and get them in the Wadena CBHH," he said.
Law enforcement transfers the individual from the ER to the CBHH, Anderson said, where they will be evaluated by a psychiatrist. This is all done during the initial 72-hour hold.
If the psychiatrist determines the person is a danger to themselves or others, an examiner's statement in support of commitment is sent to the county, he said. That initiates a pre-petition screening
usually done by a social services mental health case manager.
"They're screening for the individual's capacity to make decisions for needed treatment or needed services to get them stabilized with their mental health," Anderson said.
Then a team consisting of the adult services supervisor and two mental health case managers, including the one who preformed the screening, looks at whether a commitment should be pursued or if the person is capable of voluntarily going in for services, he said. The team always looks for the least restrictive option.
"So there's actually three individuals that are deciding at our level if we even need to pursue and petition the court for any kind of commitments," Anderson said about social services' involvement.
If they decide to petition for a commitment the judge reviews it and signs a 72-hour judicial hold, he said. Then the judge appoints an independent examiner to do another mental health evaluation and make recommendations to the court.
"And that's kind of nice, really offers the checks and balances," Anderson said. "You have that initial ER doctor saying they're a danger, you have the psychiatrist saying yeah, this person needs a commitment, the screening team decides yeah, we really need a commitment and then ... you bring in another independent examiner to say yeah, this person really does."
A preliminary hearing is also held within the judicial hold, he said. The judge makes a determination based on whether there is a preponderance of evidence that the person is mentally ill and a commitment hearing can be held.
The commitment hearing has to be held within 14 days of the original petition being filed with the court, Anderson said. The reports from the screening team, the independent examiner and the psychiatrist are all reviewed at the commitment hearing.
"Then they'll make a determination by clear and convincing evidence that the person is mentally ill and ... they're lacking the capacity to make the decisions on what kind of treatment they need to stabilize their mental health and no longer be that threat to hurt themselves or hurt anybody in the general public," he said.
If the commitment is ordered, law enforcement typically transports the person back to the CBHH, he said.
"They will stay there until the treatment team feels that they are stable enough to be discharged back into the community," he said.
A commitment typically lasts six months, Anderson said. They have to update the court every 60 to 90 days about the person's progress.
The case manager gets even more involved in the individual's case during commitment, he said. They assist in after-care planning to make sure other services are lined up to support that individual once they come out of the inpatient setting and go back to their home or wherever they are living.
Information regarding the complete commitment process is described in Minnesota Statutes, chapter 253B; special rules of procedure governing proceedings under the Commitment Act; and applicable court decisions.
Commissioner Lane Waldahl asked if it's easier for Wadena doctors to commit people with the CBHH located here.
Miller said no, it isn't.
The cost of commitments has changed for the county since the 16-bed CBHHs were built to replace the old regional treatment centers. It is significantly cheaper, according to Miller.
An average yearly cost for the county used to be $33,000 under the RTC system, Miller said. It's now about $6,000.
The county used to cover 100 percent of the cost of holds and 15 percent of the cost after the hold when the RTCs were operating, she said. The cost shifted to Medicaid when the state transitioned to CBHHs.
Social workers also don't have to make as many two-hour drives to Fergus Falls or Alexandria, she said.
"So there's a real change there," Miller said.