The Brisbane Report, Nancy D. Feldman, J.D. for New Jersey Protection and Advocacy, Inc.
PART 4 - THE WAITING ADOLESCENTS AT BRISBANE
State’s Failure to Provide Placement Leads toProlonged, Damaging Institutionalization
Definition of CEPP
CEPP, or Conditional Extension Pending Placement, is the legal status applied to Brisbane patients who no longer meet the standard of dangerousness required for their civil commitment. As described by the court rule pertaining to the civil commitment of adults: "If a patient otherwise entitled to discharge cannot be immediately discharged due to the unavailability of an appropriate placement, the court shall enter an order conditionally extending the patient's hospitalization.…" R. 4:74-7(h)(2).
Extremely High Percentage of Adolescents at Brisbane
Waiting for Placement
CEO Grimaldi acknowledged that the Brisbane population has a high percentage of patients on CEPP status, on average 60%, and as high as 80%. A review of three Brisbane Weekly Status Reports shows that the average percentage of the population waiting for placement is closer to 70%. According to a late January 1998 Report, the hospital population was 40, with 70% of the patients on CEPP status. A late April 1998 Report showed that with a hospital population of 31, 65% of the adolescents were on CEPP status. According to a third Weekly Status Report from mid-October 1998, 23 adolescents out of a total hospital population of 28, or 82%, were on CEPP status.
This high percentage of Brisbane hospital patients on CEPP status is related to two complex issues. One, patients appear to be put on CEPP status more quickly than in the past. And two, finding less restrictive placements for those patients who no longer require civil commitment is difficult and delays discharge.
Patients Ready for Discharge Soon After Arriving at Brisbane
The late January 1998, and the late April 1998, Status Reports show that of the patients on CEPP status, at least 60% were found ready for discharge after less than 30 days at Brisbane. According to the January 1998 Report, 61% of these patients had been at Brisbane less than one month when they were found to be no longer in need of commitment. According to the April 1998 Report, 60% of the CEPP patients had been at Brisbane less than one month when put on CEPP status. There are several possible reasons for this rapid turn-around from commitment to CEPP status. Older adolescents may be found no longer in need of commitment more quickly because, as described above, the dangerousness standard for commitment for minors who are 14 years old or older is now the same as for adults. CEO Grimaldi noted that with improved medications, many patients are able to be stabilized quickly.
Another factor in the rapid readiness for discharge may be the shorter period of time that severely mentally ill patients are staying at the CCIS units. Having been sent to Brisbane because they could not be stabilized during the very short (10 to 12 days) hospitalization at the CCIS unit, many patients clearly do not require long-term inpatient psychiatric hospitalization. A longer stay at the CCIS unit, which was originally meant to be a 28-day facility, would enable many of these patients to avoid commitment to Brisbane.
CEPP Population: Ready for Discharge But Nowhere to Go
Although Brisbane adolescents may be ready to be discharged soon after their arrival, it can be months before they actually leave the hospital. The late January 1998 Weekly Status Report showed that 57% of the patients that were no longer in need of commitment had been on CEPP status for over two months. Two of these patients had been at Brisbane on CEPP status for nine and a half months, and ten patients had been on CEPP status between five and seven and a half months. The late April 1998 Report showed that 55% had already been on CEPP status for over two months. Five of these patients had been on CEPP status for between eight and ten and a half months.
Generally, the adolescents who wait the longest for discharge are those who are not going home, but who need to be placed in a DYFS program for continued long-term residential care (18 to 24 months.) Most of the patients on CEPP status are waiting for this type of placement. In late January 1998, only six of the 28 patients on CEPP status had a discharge plan to go home. Of the 20 adolescents on CEPP status in late April 1998, only one had a discharge plan to go home. The mid-October Weekly Status Report showed that two of the patients on CEPP status had a plan to go home, while 21 patients, out of a total of 28 in the hospital, were ready for discharge and waiting for a placement.
The adolescents at Brisbane waiting for discharge to a residential placement are considered the toughest children in the mental health system to place. Many have multiple diagnoses, including developmental disabilities, substance abuse problems and a history of being management problems and having multiple placements. Hospitalization in Brisbane places a stigma on adolescents and makes programs reluctant to accept them. It is hardest to find a placement for adolescents who are sexual offenders, have a history of arson, or are approaching age 18. It is generally acknowledged that New Jersey does not have appropriate programs for these hardest-to-treat adolescents. Some patients end up going to any program with a vacancy that will accept them, not necessarily the best program for their needs. Other Brisbane patients are discharged to programs that are located out of state.
DYFS Plays Key Role in This Long Wait for Placement
Once a Brisbane patient is found to be ready for discharge to a residential placement, DYFS is responsible for finding that placement. For patients on CEPP status, the speed at which a placement is found and the overall length of their stay at Brisbane depends on DYFS caseworkers, who may not only be overworked, but also may not see the need to move a patient out of Brisbane as a high priority. The Brisbane case manager is also involved in the placement process and attends one CART meeting, but has no supervisory authority over the DYFS caseworker. The DYFS liaison with Brisbane, who does have the authority to supervise the DYFS caseworkers, left in May 1998. That position remained vacant into the fall of 1998.
Lucy Keating acknowledged that there is less pressure on DYFS to find a placement for the most difficult patients because they are in a safe place at Brisbane. She questioned whether the time that some patients spent on CEPP status reflected accurately the true amount of time that they had been ready for discharge or whether patients are put on CEPP status before they are ready for discharge in order to prompt DYFS to begin the process of finding a placement.
The process of finding a residential placement for a Brisbane patient ready for discharge is cumbersome, with many steps and many opportunities for delays. The DYFS caseworker posts information about the adolescent and the type of placement being sought on FMBB, the online network between DYFS and residential treatment programs. However, no movement occurs beyond this step if the facilities do not read the new listing or the DYFS caseworker does not check for responses. The next step is for application packets to be sent to potential placements. Weeks may pass before the programs respond, stating that the application is still being reviewed, that there is information missing, or that it has been rejected. If a program is interested in the adolescent, an on-site interview must be scheduled. At that point, the adolescent may reject the placement, or the program may accept the adolescent but have no immediate openings. Once on a waiting list for a residential program, the adolescent may have to remain at Brisbane for an additional three to six months until there is an opening.
The CART process, which was set up to keep children out of institutions, can actually be another source of delay for waiting adolescents at Brisbane. DYFS may delay moving ahead with the placement process until after there has been a CART review. For Brisbane patients who are going home, another source of delay is the need for the caseworker to deal with each child's school district child study team.
The process for finding placements for patients ready to leave Brisbane was set up to avoid out-of-state placements as mandated by the Bring Our Children Home Act, N.J.S.A. 30:4C-66 et seq. (1992), and the Child Placement Bill of Rights Act, N.J.S.A. 9:6B-1 et seq. (1991). Before caseworkers can consider an appropriate out-of-state placement, the child must first be rejected from all possible New Jersey placements. As a result, Brisbane patients with difficult treatment issues go through many rejections before an out-of-state placement can even be considered. Once the adolescent is approved for out-of-state placement, the same process begins again with the out-of-state programs.
Prolonged, Unneeded Hospitalization Has
Damaging Impact on Adolescents
The State is failing to provide prompt appropriate treatment for adolescents who are ready to leave Brisbane. Instead, it is relying on this restrictive psychiatric institution as a temporary haven, calling it a "safe" option for adolescents who no longer need commitment, but have no where else to go. The State’s reliance on Brisbane as a "place to wait" is inappropriate and unacceptable, legally and morally.
The wait for placement while on CEPP status has a detrimental impact on the adolescents at Brisbane. CEO Grimaldi compared the feelings of intense frustration of these patients to the way that college students would feel if they completed all required course work but are then told that they cannot graduate. Instead, they must stay in college and do nothing but wait until a diploma for them becomes available.
He acknowledged that this wait for someplace to accept them coupled with the repeated rejections exacerbates their feelings of neglect and abandonment. Although ready for discharge, their mental health begins to deteriorate as months pass and they remain hospitalized. The adolescents on CEPP status correctly perceive themselves as stuck in the place they came to when they were sick. They have no opportunities to socialize or attend school with peers except for the hospital patients. As they wait, some adolescents regress so much that they must be re-committed to the hospital.
State’s Reliance on Brisbane as "Place to Wait" May Violate
State and Federal Law
The State’s use of Brisbane to house adolescents on CEPP status not only injures the adolescents confined there and masks the lack of appropriate mental health services, but also may be in violation of state and federal law. The use of CEPP status was established in New Jersey in the context of elderly mentally ill patients who had spent almost their entire adult lives in state institutions. In re S.L., 94 N.J. 128 (1983). For these elderly, long-term patients, it was reasonable for them to spend several additional months in the institution until an appropriate placement could be found. In contrast, CEPP status is not reasonable for teenagers who may be at Brisbane for less than a month when they are found no longer to need commitment and for whom the extended wait for a less-restrictive placement may jeopardize their still fragile mental health and their ability to ultimately function in society as adults.
The State's use of Brisbane to confine adolescents on CEPP status may also violate the integration mandate of the Americans with Disabilities Act (ADA). Federal courts have recently confirmed that under the ADA, mental patients have the right to services in the most integrated setting appropriate to their needs. L.C. v. Olmstead, 138 F. 3rd 893 (11th Cir. 1998), cert. granted, ___ U.S. ___ (1998); Kathleen S. v. Department of Public Welfare, 10 F. Supp.2d 460 (E.D. Pa. 1998).